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iUMMER 2004 

Harvard Medina! 



n Humpty Dumpty Be Put Back Togef 

The Health Care Financing Crisis Has Physicians Scrambling for Answers 



Herrman Blumgart '21 was known 
as the father of diagnostic nuclear 
medicine. In 1 927, while at the 
Harvard-affiliated Thorndike 
Memorial Laboratory at Boston 
City Hospital, he pioneered the use 
of radioactive tracers to diagnose 
heart disease. The following year, 
he was recruited to Beth Israel 
Hospital, where he was named 
physician-in-chief in 1946. 

L M li E R 1 

T\ t t -i 


Letters 3 

Pulse 4 

A joint degree program, HMS history 
online, an integrated clerkship, obesity 
among children, a new program in 
Dubai, Harvard hospital rankings 

President's Report 7 

bx Eve J. Higginbotham 

Bookmark 8 

A review by Elissa Ely of Murder Is No 
Accident: Understanding and Preventing Youth 
Violenee in Amcriea 

Bookshelf 9 

Benchmarks 10 

Alumna Profile 54 

Jill Stein is trying to bring a beacon of 
medical understanding to Beacon Hill. 
by Beverly Ballaro 

Class Notes 56 

Obituaries 60 



Seeds of Change 12 


Dream On 18 


Vision and Style 20 

by MARK E [.LA Z A N N I 

Can Humpty Dumpty Be Put Back Together? 24 


American Pie 28 


Hard Labor 32 


A Doctor's Gamble in Nevada 35 



Building Bridges 38 


Reports from the Classes 42 

Caver photograph by Stephen Webster ^'ff 


Harvard Medical 


In This Issue 


w^M Bulletin to press. Our cover article by Mitchell Rabkin '55 describes 
a surgical technique for repairing the increasingly broken Humpty 
Dumpty of health care financing. Yet, as we have covered this topic in the 
Bulletin for many years, always with the same dire warnings, it is difficult not 
to feel like Chicken Little. For a long time we've joined many other small 
voices in pointing out that the sky is not intact, but the barnyard we inhabit 
seems to be populated by generally placid creatures with only faintly uneasy 
expressions on their faces. Indeed, as Steffie Woolhandler observes in this 
issue, large chunks of the sky have already fallen around us, yet no real action 
has been taken to address this fact. 

It is hard for me to understand why the national reaction is so tepid. As I 
write this, the media are reporting that another 1.4 million Americans have 
lost health insurance, bringing the total number without coverage to about 
one-sixth of the population. These folks know the impact of a sky in shards. 
But, in the nature of things, nothing has landed all that close to the farmer's 
house. Perhaps that's the reason for complacency. I haven't lost my health 
insurance, nor has any member of Congress or any state legislator. I'm sure 
judges are protected, and I can't imagine there's an insurance executive in the 
country who is at risk of post- celestial stress disorder. 

Terminology itself must be part the problem. Health care financing? As long 
as we go on talking about "health care financing," my guess is that there will 
be no groundswell for change, because the phrase itself implies: "leave it to the 
experts." But how do you phrase the problem in a way that doesn't sound 
idealistic, socialistic, or politically naive? In an era when "torture" is being 
defined down, "disability," "early death," "bankruptcy," and "despair" must 
be losing their punch. 

The only place any real change can originate is at the national level. 
Someone, somewhere in the upper reaches of government, would 
have to make an active decision to bring about serious 
change. This seems to have been possible in essentially 
every other industrialized country, where some form 
of universal coverage exists. But bodies at rest tend 
to remain at rest, as Newton taught us. Or, to put it less kindly, 
there's a great need for the well-heeled and well-insured leaders of our 
country to be a little less chicken. 


&M,\ (/U 


William Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro, PhD 


Janice O'Leary 




JudyAnn Bigby 78 
Rafael Campo '92 

Elissa Ely '88 

Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McEvoy 75 

James J. O'Connell '82 

Nancy E. Oriol 79 

Eleanor Shore '55 


Laura McFadden 


Eve J. Eugginbotham 79, president 

Joseph K. Eturd, Jr. '64, president-elect 1 

Steven A. Schroeder '64, president-elect 2 

Paula A.Johnson '85, vice president 

Phyllis I. Gardner 76, secretary 
Kathleen E. Toomey 79, treasurer 


Nancy C. Andrews '87 

Gerald S. Foster '51 
Donnella S. Green '99 
Linda S. Hotchkiss 78 
Katherine A. Keeley '94 
Barbara J. McNeil '66 
Laurence J. Ronan'87 
Mark L. Rosenberg 72 

Kenneth I. Shine '61 


Daniel D. Federman '53 


Nora N. Nercessian, PhD 


Joseph K. Hurd '64 

The Hanard Medical Ahimm Bulletin is 

published quarterly at 25 Shattuck Street. 

Boston, MA 02115 L by the Harvard 

Medical Alumni Association. 

Phone: (617) 384-8900 • Fax: (617) 384-8901 

Email: bulletin&'hms. 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191 7757 • Printed in the U.S.A. 






The Write Stuff 

I cannot recall when I last so enjoyed 
an issue of the Bulletin, cover to cover. 
The Autumn 2003 issue, with its spe- 
cial report on the neurobiology of the 
arts, arrived at a time when I had start- 
ed to draft a personal essay. The writ- 
ing was an enormous struggle, similar 
to a patient having to relearn how to 
walk. I was depressed. I believed that 
my writing biceps had atrophied 
from neglect. 

So it was with tremendous interest 
that I read the interview with Alice 

Flaherty '94, in which she talked about 
hypergraphia and its opposite, writer's 
block. I felt I was sitting at the table, 
drinking in an incredibly intimate and 
informative conversation. When she 
said that she believed that years of writ- 
ing medicalese can cause the cortical 
atrophy of the creative writing center, 
I felt empowered to persist. 

I am not hypergraphic. But, like a 
pianist, I am practicing, practicing, prac- 
ticing. Thank you for this. 


Fall Flattery 

I just received the Autumn 2003 issue 
of the Bulletin. It is great — a major 
triumph! Congratulations. 


Beauty and the Beast 

My husband and I are fighting over the 
issue on the neurobiology of the arts 
(we're both HMSers). The beast won 
today and ran off with it to work! 


Many Happy Returns 

Even though Harvard Medical School 
does not formally organize reunions 
beyond the 60th, the Class of 1939 held 
its unofficial 65th class reunion on 
Alumni Day of this year. Of the original 
125 members, there are 28 survivors and 
of that group we had seven present. Our 
reunion included a visit to Arthur and 
Anna Pier in their home. 

Most of our group has reached the 
age of 90 and yet we were able to have 
an enjoyable time, particularly during 
the Quadrangle meeting with Deans 
Joseph Martin and Daniel Federman '53. 
We ate dinner at John Stanbury's 
house, where we had not only our 
reunion members, but also about eight 
other guests, including some spouses 
and children. 

At any rate, the Class of 1939 is still 
alive and kicking, and we want to send 
greetings to every one of our friends 
in Boston. 


The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (617 384 8901); or 
email ( Letters may 
he edited for length or clarity. 





There's No Business Like Co-Business 


Business School (HBS) will launch a 
five \ear joint MD-MBA program in 
September 2005. 

Although several U.S. medical schools 
offer joint medical and management 
degrees, the five-year HMS-HBS pro- 
gram will stand apart in fostering intel- 
lectual integration of medicine and 
management. Students will spend the 
first three years at HMS, the fourth year 
at HBS, and the fifth year divided 
between HBS and HMS. Yet the man- 
agement perspective will be introduced 
as a prematriculation online module 
that becomes increasingly pervasive 
during the first three years at HMS, cul- 
minating in a fully integrated fifth year. 

About a dozen students over the past 
two decades have obtained separate 
degrees from HMS and HBS. A major 
difference between the pioneering days 
and the new program is that students 
will be accepted concurrently to the 

MD-MBA program. Matriculation will 
be challenging in that applicants must 
be accepted by each school indepen 
dently Once the program starts in the 
fall of 2005, though, previously enrolled 
students in both schools may take the 
course offerings, and some of those stu- 
dents may subsequently decide to apply 
to the joint program. 

Malcolm Cox 70, HMS dean for med- 
ical education, says coursework toward 
the new joint degree will enable students 
to reach beyond traditional boundaries. 
"The program," he says, "will provide the 
opportunity for all medical students, 
not just those enrolled in the new pro- 
gram, to better appreciate the critical 
importance of strong management 
skills in improving the U.S. health care 
delivery system." ■ 

They Oughtta 
Be in Pixels 



young men at Harvard Medical School 
posed for a group photo. Clustered together 
in the Pathology Department, they stood 
stiffly in their white coats, a skeleton 
perched forlornly on a table behind them. 

Web users now have online access to 
this and other archival images of HMS. 
These historical photos, a critical part of 
the School's institutional memory, document 
the development of medical education, clin- 
ical practice, and the Longwood Medical 
Area. Eventually, more than 4,000 images 
will be described in Web-based subject 
guides, which will include scans of 1,600 
representative images. Click on www.countway. 
guides. shtml to view the initial guides. ■ 


Rebuilding Blocks 


rolled out a new, integrated 
clerkship at Cambridge Hos 
pital. Innovative in its inter 
disciplinary, comprehensive approach, 
the clerkship will replace traditional 
block rotations with a yearlong immer 
sion in the illnesses, treatments, and lives 
of 40 to 50 patients, beginning with their 
initial symptoms. 

Participants in the clerkship will con- 
sist of an initial group of eight third-year 
students, including Dante Foster '06. 
Foster is looking forward to the unique 
learning experiences that will come from 
finding herself connected with individual 
patients rather than a particular service. 
"In helping patients from the onset of 
symptoms all the way through the journey 
of diagnosis, treatment, and follow-up," 
she says, "I will witness the entire process 
with those patients as my teachers." 

The program was developed by David 
Hirsh, HMS instructor in medicine, and 
Barbara Ogur, HMS assistant professor of 
medicine, who built on the educational 
foundations laid by HMS professors 
Ronald Arky, William Silen, and others. 
The clerkship, funded by the Academy 
at HMS and a grant from the New York 
Academy of Medicine, is one of the first 
pilot projects in the ongoing Medical 
Education Reform Initiative, led by 
Malcolm Cox 70, the HMS dean for med- 
ical education. It exemplifies a new 
model for clinical education in which stu 
dents have both longitudinal and immer 
sion experiences in patient care. 

Managed care and increasingly less- 
invasive technology have combined to 
attenuate admissions and hasten dis- 
charge, Ogur says. As a result, third 
year students see illnesses as disparate 
snapshots rather than as movies with a 
beginning, a middle, and an end. These 
changes have diminished the students' 
contact with the patients. 

In the new clerkship, students will 
follow about fifteen patients from inter- 

Downsizing Junior 


has risen significantly around the world in the past 25 years. During this period, 
the rate of overweight and obesity among Americans has increased two- to three- 
fold. The rate among African American and Hispanic young people currently 
stands at 40 to 45 percent; among non-Hispanic whites, it is 25 to 30 percent. 

Children's Hospital in Boston is working to combat these alarming trends 
through Optimal Weight for Life (OWL), the largest pediatric obesity program in 
New England. At the OWL multidisciplinary care clinic, physicians, nurse prac- 
titioners, dieticians, and psychologists provide care, develop treatments, and 
promote prevention efforts for more than 500 new patients each year. 

According to David Ludwig, director of the OWL program and an HMS asso- 
ciate professor of pediatrics at Children's, overweight and obesity are influenced 
by genetics, diet, physical activity, and psychological factors. OWL combines 
comprehensive medical examinations, nutritional counseling, physical activities 
training, behavior modification, and group therapy to effect lifestyle changes. 

"Fundamental changes in the social environment will be needed to address 
what is essentially becoming a public health crisis," 
Ludwig says. "Solutions to negative environmental condi- 
tions exist, but will require measures to change problems 
in food quality, policy, and advertising and also 
increased funding for public programs for school 
children, like physical education." ■ 

Visit www. 

Jamae Kawauchi is assistant director of the Center of 
Excellence in Minority Health and Health Disparities at HMS. 


org/owl to learn 

more about 

Optimal Weight 

for Life (OWL). 

nal medicine, ten from pediatrics, and 
five to ten from psychiatry, neurology, 
and other areas. The students will also 
see numerous patients outside of their 
longitudinal cohorts. The patient-cen- 
tered clerkship is designed to allow stu- 
dents to gain skills that will be transfer- 
able to any specialty, Ogur says. 

"By giving the students the capacity to 
think deeply and by integrating the vari 
ous sciences into their thinking, we will 

enhance their curiosity," Ogur adds "By 
also creating strong connections with 
patients over time, we hope to rein\igo 
rate that core aspect of medicine, which 
is to put doctors' curiosity and skills in 
service to their patients." 

Foster is eager for the experience. "The 
clerkship," she says, "should help me to 
get to know the patients who allow me to 
participate in their care not just as clinical 
puzzles but as whole human beings." ■ 





Golden Retrievers 


award from the Council for Advancement and Support of Education 
(CASE), based on two issues whose special reports focused on money and 
medicine and the neurobiology of the arts. Each year this national grand 
gold award is sponsored and judged by the editors of Newsweek. The first 
graduate school magazine to win the Sibley Award since 1 994, the Bulletin 
was automatically entered into competition for the award based on its 
recent gold medal in the professional and graduate school magazine cate- 
gory. The Bulletin also won a silver medal from CASE in the periodical spe- 
cial issues category for its special report on the neurobiology of the arts. ■ 

Bridging the Gulf 


programs at HMS and president and chief executive officer of 
Harvard Medical International, joined Saeed Al Muntafiq, 
chief executive officer of Dubai Healthcare City, and George 
Thibault '69, director of the Academy at HMS, in breaking ground on the 
Harvard Medical School Dubai Center, scheduled for completion in 2005. 
Harvard Medical International and Dubai Healthcare City have already 
established a joint postgraduate training program to develop a cadre of 
physician-specialists who will contribute to the advancement of medicine 
and health in Dubai, the United Arab Emirates, and the entire Gulf Region. 
It is hoped that research funded through the new center will help to 
drive a resurgence in scientific and medical excellence in the Arab 
world — a centuries-old tradition that has faded in recent years. In 
addition, an endowment created through the Harvard Medical 
School Foundation for Dubai will seek to make Dubai Healthcare 
City's services available to as broad a population as possible. 

"Dubai Healthcare City has generated interest among health care 
professionals both within and outside of the Gulf Region," says 
Joseph Martin, dean of Harvard Medical School, "simply by building 
their mission around the real needs of the people in the region." ■ 

Good Hospital Fare 


placed high in U.S. News and World 
Report's annual rankings of the nation's more 
than 6,000 medical centers. Cited in the 
2004 report as two of only 1 4 "honor roll" 
centers — hospitals that excelled in at least 
six specialties — were Massachusetts Gen- 
eral Hospital (ranked third) and Brigham 
and Women's Hospital (ranked 12th). 

Harvard hospitals also received recogni- 
tion for their outstanding work in 17 spe- 
cialties. Massachusetts General Hospital 
ranked first in psychiatry; second in hor- 
monal disorders; third in neurology and 
neurosurgery and orthopedics; fourth in 
digestive disorders, gynecology, kidney 
disease, and respiratory disorders; fifth in 
geriatrics and heart and heart surgery; 
seventh in rheumatology; eighth in urology; 
12th in cancer; and 17th in pediatrics. 

Brigham and Women's Hospital ranked 
first in kidney disease; third in gynecology; 
sixth in heart and heart surgery; eighth 
n hormonal disorders and rheumatology; 
1 lth in digestive disorders; 16th in respira- 
tory disorders; 1 8th in orthopedics; 23rd 
in geriatrics; 24th in neurology and neuro- 
surgery; and 25th in urology. 

Children's Hospital Boston ranked sec- 
ond in pediatrics. Massachusetts Eye and 
Ear Infirmary ranked third in otolaryngolo- 
gy and fourth in ophthalmology. Dana- 
Farber Cancer Institute ranked fourth in 
cancer. McLean Hospital ranked fourth in 
psychiatry. Spaulding Rehabilitation Hospi- 
tal ranked eighth in rehabilitation. And 
Beth Israel Deaconess Medical Center 
ranked 1 2th in hormonal disorders, 1 8th in 
geriatrics, 26th in digestive disorders, and 
40th in neurology and neurosurgery. ■ 

Nominations Sought 


alumni, Daniel Federman '53 will be 
stepping down as director of alumni 
relations next June. To nominate your- 
self or another HMS graduate to take 
on this role, email Joseph Hurd '64, 
incoming president of the Alumni 
Council, at 




The Changing Mosaic of Harvard Medical School 



this past year. In my farewell column, I wanted 
to offer just a few highlights from my term. 

During the Alumni Council's fall meeting we 
learned about the efforts of Joan Reede, HMS 
dean for diversity and community partnership, to extend the 
rich intellectual resources of HMS into the community and 
to encourage young people in Boston to contemplate careers 
in medicine. We also applauded the efforts of HMS to diver 
sify its student population in terms of ethnicity, socioeco- 
nomic status, and gender. Now focus must move, however, 
to those who will teach Harvard's changing mosaic. Only 
3 percent of our medical school faculty members are persons 
of color. Of the 3,586 faculty members at the level of assis- 
tant professor and higher, there are only 9 professors, 31 
associate professors, and 64 assistant professors of color. 
We must find ways to change this story. 

and an initiative to develop ways to bring to bear the talent and 
intellect of the more than 8,000 alumni on the issues that affect 
us all. And at our June meeting, we narrowed a long list of 
issues to two areas in which we hope to engage alumni over the 
next two years: the plight of the uninsured and the preserva- 
tion of professionalism in medicine. 

The Council must now undertake the daunting task of trying 
to fill the shoes of Daniel Federman '53, our director of alumni 
relations. We all know that Dan is irreplaceable; he alone can 
recall anecdotes about — in addition to remembering the names 
of — many of the thousands of graduates in the past 50 years. He 
has announced his retirement beginning next summer, howev- 
er, and the Council has begun to formulate a search committee. 
We have asked Dean Martin to strongly consider maintaining a 
separation in functions of the director of the alumni hind and 
the director of alumni relations, so we can continue to relate to 
alumni and advise the dean beyond issues related to fundraising. 

We applauded the efforts of HMS to diversify its student 
population. Now focus must move, however, to the HMS 
faculty, only 3 percent of whom are persons of color. 

'To that end, on February 12, 2005, Dean Joseph Martin will 
announce the Akin F Poussaint, MD Visiting Lecture Fund to 
bring HMS graduates of color back to Boston. Such exposure 
should encourage more medical students to consider academ 
ic careers and ultimately choose HMS as their academic home. 
According to a survey conducted by Alane Shanks, associate 
dean for educational administration and finance, to which 
more than 300 graduates of color responded, the pool of can 
didates for this lectureship is rich. It includes a college presi 
dent, a foundation CEO, a corporate executive, and Institute 
of Medicine scholars. The survey will soon be available on the 
HMS alumni website. 

The fall meeting was followed by the opening ceremony of 
the New Research Building, which coincided with the 100th 
anniversary of the groundbreaking of the Quadrangle. A 
copy of the award-winning Harvard Medical Alumni Bulletin v\ill 
mark the alumni presence at this celebration when the time 
capsule is opened in another 100 years. 

In March, the Council sequestered itself for a day and a half 
to consider strategic issues. This retreat resulted in a constitu 
tional amendment that will be presented to alumni next June, 
a commitment to increase awareness of student indebtedness, 

In addition to Dan's departure, we are saddened that Nora 
Nercessian, associate dean for alumni programs and special 
projects, will be leaving us at the end of the year. Nora has 
been the resident historian of HMS and has worked extraor 
dinary hours on our behalf. In her spare time, she has written 
five books. The most recent one. Against All Odds, details the 
incredible stories of the first graduates of color from HMS. It 
will be officially celebrated at a special event on October 7. 

I would also like to recognize the contributions of our retir- 
ing Council members: Paula Johnson '85, Barbara McNeil '66, 
Laurence Ronan '87, and Mark Rosenberg '72. Moreover, a 
number of individuals who work tirelessly on behalf ot the 
alumni deserve our gratitude as well: Tenley Albright '61, 
William Bennett '68, Anne Benware, Paula Byron, Jean 
Hurd, Patrick Rivera, and Kristen White. 

My commitment to HMS has been deepened by this expert 
ence. Thanks again for the privilege, and I hope those of you 
who have not yet done so will become involved in the Council 
and reconnect to this outstanding medical school. ■ 

Eve J. Higpnbotham 79 is chair of the Department of Ophthalmology 
at the University of Maryland School of Medicine. 




Murder Is No Accident 

Understanding and Preventing Youth \ iolence in America, 
by Deborah Prothrow Stith 79 and Howard R. Spivak 
(John Wiley & Sons, 2003) 


hiked up on the porcelain sinks, with high hair and ciga- 
rettes. There was threat the second the door closed behind 
you. Outside that door, the girls led distant lives on the 
other side of the city. Some dropped out of school. Some 
had babies. Few went to college. Inside the door, they 
smoked, looking indifferent, angry, amused. Sometimes 
they would ask for money. They were a city unto them- 
selves, the girls in the bathroom. You used your own bath- 
room before you left home. 

We knew there was violence in their world 
but we never cared to know more. They 
might share our school building, but most 
of the time they Lived too far away to worry 
about. They were Them. But since the 1999 
shootings at Columbine, They have become 
Us. Teen violence has risen in the middle 
and upper classes. 

Murder Is No Accident: Understanding and 
Preventing Youth Violence in America is written by 
two Boston physicians, Deborah Prothrow- 
Stith 79 and Howard Spivak. It is so earnest, 
so unabashed, and so without ulterior motive 
that it deserves earnest and unabashed atten- 
tion. The authors offer no glad hands or innu- 
endo, and they don't ask to see the baby pic- 
tures before bluntly making their demand. "We 
want you," they write, "to join...a movement." 

Youth violence as epidemic has been clearly document- 
ed, first in poor communities, then in suburban schools; our 
homicide rate is the highest by far among the 26 wealthiest 
industrialized nations. Seventy-five percent of victims are 
between 15 and 34 years old, and 75 percent of murders are 
committed with guns. It was easy to relegate the problem 
to the criminal justice system, where responses are post- 
facto, punitive, and crisis-oriented. They are also expen- 
sively geared toward individual offenders. No one had con- 
ceived of violence as a medical issue, even though epidemics 
are public health terrain. Prothrow- Stith, a former Massa- 
chusetts commissioner of public health, first gathered data 
as an HMS student — but not in class. She learned her facts 
from a copy of Ebony magazine. 

Murder Is No Accident argues definitively that youth violence 
is a public health problem, and a preventable one. It can be 
broken down by analysis into risk and protective factors. 

The risk factors are obvious: poverty, alcohol, gun availabili- 
ty, romanticization in the media, and exposure in homes and 
communities overwhelmed with trauma. 

Some of the protective strategies seem equally obvious, 
especially those extending beyond the reach of the justice 
system: maximizing cognitive development in children and 
adolescents, teaching conflict resolution, legislating against 
handguns, countering media violence with media Literacy, 
decreasing household exposure to \iolence of all sorts. So why, 
the authors wonder, haven't these strategies been implemented? 
Then the authors grow bolder. They suggest that, 
instead of expelling kids under a zero -tolerance policy, 
schools need to draw them closer with assessment and fol- 
low up. Why not teach parenting skills in high school? 
Why not mount violence prevention media campaigns? 
Why not turn school buildings into multiservice 
centers wiiose doors stay open after the aca- 
demic day ends? Why not follow children 
admitted to hospitals with injuries back 
home after discharge, just as there is follow- 
up for children admitted with asthma? Why 
not bring the mountains to Mohammed? 

The movement the authors describe works 
community up instead of policy down. It is like 
building a war map with pushpins connecting 
nonadjacent regions, only this is a peace map. 
The authors call it a "deliberate Johnny Apple 
seed approach," and it has worked in Boston, 
where Prothrow- Stith and Spivak "trained 
somebody who trained somebody else who 
recruited and trained somebody else," until thou 
sands of people were involved. 
A school curriculum for high-risk youth widened into 
collaborations between community workers and teens, 
police and clergy, courts and mental health providers, ten- 
ant associations and youth groups, police and probation 
officers, hospitals and outreach workers. No sector was 
left out, and no sector was left alone to respond. It was the 
broadest spectrum of treatment possible, and the patient 
responded. In Boston, the rate of gun-related adolescent 
homicides dropped from almost one a month in 1989 to 
none at all in 1996. These are numbers with clout. 

But the writers are — remarkably — unimpressed with 
themselves. They have no time for laurels. As the book clos- 
es, they warn that a third epidemic is upon us: 25 percent of 
adolescents arrested for \iolence are now females. The girls 
in the bathroom who haunted the past also haunt the future. 
And in Boston, the number of adolescent homicides has 
recently started to creep up. Just because violence can be 
stopped doesn't mean that it will. ■ 

Elissa Ely W is a lecturer on psychiatry at HMS. 






The Harvard ^ 
Medical School 

Taking £ 
Control of 



How to Win the Nobel Prize 

An Unexpected Life in Science, by J. Michael 
Bishop '61 (Harvard University Press, 2003) 

In 1989 the author, a microbiologist, and 
Harold Varmus won the Nobel Prize for 
their discovery that normal genes can 
cause cancer under certain circum- 
stances. Here Bishop tells readers how 
they made their discovery. In his lively 
narrative, punctuated with vivid anec- 
dotes about some of our deadliest micro 
bial enemies, he weaves together two 
strands of medical history. 

Cancer Neurology in Clinical Practice 

edited by David Schiff "88 and Patrick Y. 
Wen (Humana Press, 2003) 

This book emphasizes common neuro- 
logical complications of systemic cancer 
rather than focusing on brain tumors. It 
serves as an up to date reference for both 
neuro-oncologists and physicians who 
are not specialists. The authors describe 
neurological symptoms and complica- 
tions of cancer and cancer therapy, as 
well as neuro-oncologic complications of 
organ- specific malignancies. 

No Margin, No Mission 

Health Care Organizations and the Quest for 
Ethical Excellence, by Steven D. Pearson, 
James E. Sabin '64, and Ezekiel J. 
Emanuel '85 (Oxford University Press, 2003) 

this book addresses the challenge of dis- 
pensing health care fairly in a competitive 
market. The authors take best practices 
from U.S. organizations already using 
them and create a template for excellence. 
Each chapter defines a problem and offers 
remedies based on case examples. 

The Harvard Medical School Guide 
to Taking Control of Asthma 

A Comprehensive Prevention and 
Treatment Plan for You and Your Family, 
by Christopher H. Fanta 75, Lynda 
M. Cristiano, and Kenan Haver, with 
Nancy Waring (Free Press, 2003) 

This commonsense guide is designed to 
help the more than 15 million Americans 
who suffer from asthma lead fuller, more 
active lives. It outlines cutting edge ther- 
apies as well as complementary and alter- 
native medical treatments. The authors 
describe potential situations and offer 
suggestions for managing them. They 
also address special asthma concerns for 
children, women, and the elderly. 


An Introduction to the Science of Sleep, 
by J. Allan Hobson '59 
(Oxford University Press, 2003) 

The result of a two-year national project, 
Best Ethical Strategies for Managed Care, 

Hobson, a psychiatrist, replaces the dream 
mystique with sleep science for the layper 
son. He compares the neurobiology of the 
sleeping and dreaming brain with that of 
the waking brain. His bottom line: dream 
ing has no prophetic quality; it's a physio 

logical process that is necessary for sur- 
vival. The neurobiology of brain activation, 
he says, is what determines the odd, asso- 
ciative nature of dream consciousness. 

Global Health Challenges for 
Human Security 

edited by Lincoln Chen '68, Jennifer 
Leaning, and Vasant Narasimhan '03 
(Harvard University Press, 2003) 

Harvard's Global Equity Initiative, found 
ed by Chen, commissioned the contribu 
tions to this volume, w T hich explores the 
evolving relationship between global 
health and human security. The book cov- 
ers health epidemics caused by infectious 
diseases, violence, security risks, and 
poverty. Through case studies, the authors 
show that individual and collective action 
can improve global health and security. 

The Viagra Myth 

The Surprising Impact on Love and 
Relationships, by Abraham Morgentaler '82 
(Jossey-Bass, 2003) 

Morgentaler, founder of Men's Health 
Boston, uses case examples to illuminate 
what Viagra can alleviate (performance 
anxiety and erectile dysfunction) and 
what it can't (identity issues). The author 
pays special attention to the "dark side" 
of taking the drug — its potential to rob a 
man of feeling valued for who he really 
is — and examines alternatives to Viagra, 
especially for those who have had 
prostate cancer. 




The Secrets of Brain Aging Revealed 


and impaired hearing, for 
many people old age brings 
the frustration of diminish- 
ing mental abilities. For scientists who 
study aging and neurodegeneration, the 
Holy Grail has been to identify the mol- 
ecular changes underlying this seem- 
ingly inevitable decline in brainpower. 
Now, researchers at HMS and Chil- 
dren's Hospital Boston have identified a 
group of genes whose activity decreases 
with age in the human brain. The decline, 
starting as early as 40, results from dam- 
age to the brain's DNA and progresses 
at varying rates in different individuals. 
"We found that genes that play a role 
in learning and memory were among 
those most significantly reduced in 
the aging human cortex," says Bruce 
Yankner, HMS professor of neurology at 
Children's and senior author of the study, 
published in the June 24 issue of Nature. 
"These include genes that are required 
for communication between neurons." 

The results suggest that aging starts 
early in adult life, and they raise the 
possibility that protecting against DNA 
damage could delay aging and age- 
related neurodegenerative conditions 
such as Alzheimer's disease. 

Yankner and his colleagues used gene 
chip technology to measure the expres- 
sion levels of 11,000 genes, or nearly half 
the genome, in postmortem brain tissue 
from the frontal cortex of 30 normal sub- 
jects ranging in age from 26 to 106. They 
found that 4 percent of the genes 
changed in expression between the 
young and old brains. By comparing gene 
expression patterns between different 
subjects, the researchers found that gene 
activity was similar among all the young 
adults and was uniformly changed 
among the over-70 subjects. But the mid- 
dle-aged group between 40 and 70 years 
old showed much more variability. 

"Some of those individuals looked 
more like the young group, while the 
transcriptome patterns of others looked 

more like the old group," Yankner says. 
"It's a case where science validates several 
thousand years of common sense by sug- 
gesting that people age at different rates." 

The brain does not passively submit 
to the passage of years, however. The 
genome analysis identified increases in 
a group of protective genes that defend 
tissues against oxygen damage. The 
increase in antioxidant genes, DXA repair 
genes, and stress-response genes suggest- 
ed to Yankner and his colleagues that the 
aging brain might be fighting increased 
oxidative stress. These observations also 
led the researchers to hypothesize that 
some of the genes that were less active in 
the aging brain might be disproportion- 
ately affected by oxidative DNA damage. 

To look at DNA damage in brain 
tissue, Tao Lu, a research fellow in 
neurology in Yankner's lab, devised a 
method that first cleaved DNA specifi- 
cally at sites of damage, then measured 
how much intact DNA was left in any 
particular gene by quantitative poly- 
merase chain reaction. "Developing this 
assay really opened a door for us," 
Y'ankner says, "because it enabled us to 
resolve oxidative DNA damage to any 
sequence in the genome." The scientists 
used the assay to look at 30 different 
genes and saw damage in some genes 
after age 40 and in all genes after age 70. 

The researchers found that damage 
was most common in the promoter 
regions of genes. This made sense, 
because promoters tend to be high in 
guanine and cytosine, bases that are 
most sensitive to oxidative damage. 
DNA damage that occurs in these 
regions is not repaired during normal 
gene activity, but gets reversed only 
when cells divide. Since neurons do not 
divide, promoter damage can accumu- 
late and, the researchers reasoned, 
could lead to the depressed gene activi- 
ty detected in aging brains. 

That's exactly what seems to happen, 
the researchers found. They discovered 
that the genes that were downregulated 



Research Digest 

with aging accumulated greater damage 
than genes whose expression was stable 
or increased. Using neuron cells in cul 
ture and even by damaging the DNA in 
a test tube, the researchers showed that 
age -sensitive genes are more susceptible 
to oxidative damage and less amenable 
to repair than the genes that do not 
change with age. Some of the DNA 
damage could be repaired in culture, 
suggesting that not all aging related 
changes are irreversible. 

The link between normal aging, DXA 
damage, and neurodegenerative disease 
is of particular interest for Yankner. 
who has studied Alzheimer's disease 
for many years. While the role of DNA 
damage in cancer has long been appre- 
ciated, before now it was not widely 
thought to play a role in neurodegencra 
tive diseases, Yankner said. His group 
is interested in figuring out why some 
gene sequences are more vulnerable to 
DNA damage than others and whether 
the changes of normal aging might 
trigger the molecular cascades that 
underlie degenerative diseases of aging 
like Alzheimer's and Parkinson's. 

One promising avenue for future 
work is whether measures to protect the 
genome early in adult life will pay off by 
slowing brain aging. It is too early to tell 
whether gobbling vitamins or other 
antioxidants will protect the brain, for 
example, but Yankner looks forward to 
testing such ideas in aging animal mod 
els using the gene damage assay. 

In the short term, the researchers 
look forward to completing their gene 
profiling of the aging brain using chips 
that cover the entire genome. Even then, 
Yankner says, the work has just begun. 
"I see the gene expression profile not 
as a definitive indicator of what has 
gone wrong, but as a first step in pro- 
viding a hypothesis that will be pur- 
sued by many labs to understand the 
biology of the aging brain." ■ 

Pat McCaffrey is a former intern at Focus. 


Invading pathogens are often 
chewed up into tiny bits by 
immune system scouts and spit out in the form of antigens that then trigger 
T cells to hunt down similar invaders. For years, the antigen-presenting scouts 
have been thought to dine exclusively on proteins, avoiding the bacteria's 
gelatinous carbohydrate coat. It now appears that antigen-presenting cells con- 
sume a more eclectic diet than previously thought. Dennis Kasper, Brian Cobb, 
and their colleagues in the Channing Laboratory at Brigham and Women's Hos- 
pital have essentially caught the cells in the act of taking in and degrading a 
set of carbohydrates. The findings, reported in the May 28 issue of Cell, could 
open the door to new methods for rousing the immune system to fight disease. 


In a region of DNA long considered a genetic wasteland, HMS researchers 
have discovered a new class of gene. Most genes carry out their tasks by mak- 
ing a product — a protein or enzyme. But the new one, found in yeast, does not 
produce a protein. It performs its function — in this case to regulate a nearby 
gene — simply by being turned on. HMS researchers Joseph Martens, Lisa 
Laprade, and Fred Winston found that by switching on the new gene, they 
could stop the neighboring structural gene from being expressed. "It is the 
active transcription of another gene that is regulating the process," says 
Martens, lead author of the paper in the June 3 issue of Nature. 


In the largest study of its kind ever undertaken, the World Health Organiza- 
tion's World Mental Health Survey Consortium, headed by Ronald Kessler, 
HMS professor of health care policy, has found that the proportion of mentally 
ill people who receive treatment is woefully inadequate. The survey, conducted 
in 14 countries around the globe, also revealed that as many as 85 percent of 
those with severe mental illness are not being treated at all, while many who 
are receiving treatment have no mental illness. The findings, published in the 
June 2 issue of the Journal of the American Medical Association, suggest that 
a reallocation of resources may help steer treatment to patients in need. 


An existing drug already approved by the Food and Drug Administration may 
protect newborns from brain injury and long-term neurologic problems caused 
by exci to toxicity, or over-activation of neurons, report researchers led by 
Frances Jensen, associate professor of neurology at Children's Hospital. Prema- 
ture infants are especially vulnerable to excitotoxicity. The drug, topiramate, is 
currently approved to control seizures in adults and in children over age three 
but the findings may provide the basis for a protective therapy that could be 
given to babies immediately after traumatic birth events that compromise the 
brain's blood and oxygen supply. Such events can cause long-term neurologic 
abnormalities that underlie serious conditions like cerebral palsy and epilepsy. 
"Our results indicate," says Jensen, "that a clinical trial should be considered 
to determine topiramate's safety and efficacy in newborns." 



^ 2004 ^ 






•l T i 

k -^3> 








f 6y Norman E. Borlaug 1 



Borlaug believes that 

genetically modified 

agriculture is critical to 

solving the world's 

hunger problem. 


it* ^jJ'AAMiw^. ^^^B 

s .*■ 

* 2r^l 





•Jl ^**m 



childhood. One of my earliest recol- 
lections is of the panic caused by the 
1918-19 influenza tragedy I survived 
bouts with chicken pox, measles, 
mumps, and pertussis, and I was for- 
tunate to escape diphtheria, tetanus, 
typhoid, smallpox, tuberculosis, and 
poliomyelitis. During my 90 years, I 
have been hospitalized only once, in 1934, at the Univer- 
sity of Minnesota Hospital, where I was confined with 
a life-threatening streptococcal throat infection. Sulfa 
drugs and antibiotics were not yet available, so my only 
treatment consisted of gargling with warm saltwater 

tect human, animal, and plant health. And 
that is why the ongoing debate between 
environmental zealots and researchers in 
human and veterinary medicine and plant 
science must be won on the basis of scientif 
ic data rather than emotion and rhetoric. 

Shifting Winds 

to alleviate the pain. My innate resistance allowed me a 
narrow escape; many others were not so lucky. 

In my lifetime, I have witnessed great progress in health. 
These strides have been achieved thanks to the widespread 
use of better sanitation practices; the development of vac- 
cines and drugs, including antibiotics; enhanced control of 
certain diseases; improved nutrition; and better housing and 
environments. The composite impact of these changes over 
the past century has been to increase American longevity, on 
average, by 30 years, while also improving the quality of life. 

But we have no time or place for complacency on the 
biologic front. New strains of human, animal, and plant 
pathogens continue to emerge through mutation and 
hybridization. Ancient diseases such as malaria, schisto- 
somiasis, and trypanosomiasis remain uncontrolled, and 
new diseases with disastrous consequences, such as 
HIV/AIDS, have emerged. 

Today, the world confronts these pandemic diseases. 
Unless control is strengthened, the World Health Organi- 
zation estimates that as many as 35 million people will die 
of tuberculosis over the next 20 years. Malaria alone is 
responsible for more than one million deaths a year, most- 
ly in sub-Saharan Africa. And HIV/AIDS is taking a terri- 
ble toll. More than 20 million have died from AIDS and 
more than 40 million are currently infected with HIV, 
70 percent of whom live in sub-Saharan Africa. 

That is why the development and use of molecular 
genetics are so critical to our never-ending battle to pro- 

Change is one of the few certainties of life. 
Consider human nutrition, physical exer- 
cise, and health. In earlier days, the rich were 
fat and the poor were thin, and decent peo- 
ple worried about feeding the hungry. 
Nowadays, the rich are thin and the poor are 
fat, and one of America's greatest public 
health concerns is obesity — the result of too 
much food and too little physical exercise. 
I have spent 60 years trying to increase 
food production in low-income, food-deficit nations. Bet- 
ter nutrition resulting from an increased availability of 
calories, proteins, vitamins, and minerals, combined with 
improvements in medicine, has resulted in a century of 
declines in mortality, as well as increased rates of per 
capita income in industrialized nations. Yet in densely 
populated, hungry countries such as India, Pakistan, 
China, Bangladesh, and Indonesia, these improvements 
have occurred only in the past four decades. 

In most industrialized countries, less than 3 percent 
of the population is now engaged directly in agricultural 
production and less than 20 percent lives in rural areas. 
As a result, most people in industrialized nations are igno- 
rant about the complexities of producing and equitably 
distributing food for all who come into this world. They 
are equally ignorant about the management of our forest 
resources for multiple uses on a sustainable basis. 

Urban ignorance in rich countries about agriculture, 
forestry, and fisheries — indeed, about biological sciences 
in general — has permitted anti technology critics to argue 
that humankind is being poisoned by modern high-yield 
agriculture and should return to traditional organic meth 
ods. As a result, today many people try to stop the applica- 
tion of new knowledge in molecular biology — especially 
the new transgenic biotechnological tools that offer so 
much promise for the future — from being applied to 
enhance efficiency of our food system through the develop- 
ment of improved plant varieties and animal breeds. 


Most of the opposition to agricultural biotechnology 
has come from people in affluent industrialized countries 
who believe they are protecting Mother Nature from the 
vicious designs of multinational corporations. Well- fed and 
comfortable, they seem to want an idyllic, Utopian, and 
organic world free of agricultural chemical pesticides, 
including chemical fertilizers — in short, a world without 
risk. Theirs is a rich-world argument that hurts the poor. 

Taming the Population Monster 

In principle, the human population is no enemy of nature. 
Someday, the human population may be several times larg- 
er than at present, without serious ecological harm. But 
today, many developing countries have population growth 
rates that are too high for current social institutions and 
technological knowledge to support at adequate stan- 
dards of living. Thus, short-term global population stabi- 

lization, especially in densely populated nations, is des- 
perately needed. Universal primary education — and, as 
soon as possible, secondary education — should be our 
near-term first step toward achieving population equilib 
rium in developing nations. 

During my lifetime, the world population has increased 
nearly fourfold, from 1.6 billion to 6.3 billion people. 
Although growth rates are slowing, each year we continue to 
add more than 80 million people to the world population. 
Most of them, unfortunately, are in food-deficit nations. 

Several decades ago, in Asia, the application of modern 
science and technology to food production came to be 
known as the Green Revolution. During the past 17 years, 
1 have been working in Africa with former U.S. President 
Jimmy Carter and the Sasakawa family of Japan on an 
initiative called the Sasakawa Global 2000 agricultural 
program. Our aim is to bring a green revolution in food 
production to millions of small-scale farmers. Unfortunately, 


Borlaug helped launch the 

Green Revolution to enhance 

food production in hungry 

nations. Here, farmers work the 

sugar fields in Veracruz, Mexico. 



Every day more 
than 800 million 
people worldwide 
go to bed hungry. 


progress has been painfully slow — and far less substantial 
than the inroads made in Asia 35 years ago. 

Today in Africa, widespread food insecurity and malnu- 
trition persist and have even worsened in some areas. 
Africa's food production remains in crisis, even though our 
demonstrations on hundreds of thousands of plots on farm- 
ers' fields clearly show that the technology is available to 
double and triple yields of major food crops. While the tech- 

nology is available and smallholder farmers are eager to 
adopt it, unless Africa's rural infrastructure and institutions 
are significantly improved — especially transport systems, 
energy, water, schools, and clinics — all other efforts to 
reduce poverty and hunger, improve health and education, 
and secure peace and prosperity will continue to falter. 

Achie\-ing sustainable agricultural production with equi- 
table distribution of sufficient food for the 9 to 10 billion 



people likely to be on Earth by the 
end of the twenty-first century will 
not be easy. Advances in agricultural 
research and production — and the 
efforts of the world's farmers, ranch 
ers, fishermen, and aquaculturists — 
have kept world food production 
growing faster than the population. 
Even so, at least 800 million people 
go to bed hungry most nights, not 
because there isn't enough food to go 
around but because they are too poor 
to buy or produce it. 

I often ask the critics of modern 
agricultural technology to consider 
what the world would have been like 
without the technological advances 
that have occurred in agriculture 
over the past 50 years. If we were to 
try to produce the two billion met- 
ric tons of cereal grains harvested 
today with the crop yield technolo- 
gy of 1950, we would need to culti- 
vate a total of 4.5 billion acres of 
land instead of the 1.8 billion acres 
that are actually used. Obviously, 
such a surplus of land is no longer 
available, especially in populous 
Asia. Moreover, even if it were avail 
able, it we were to try to bring an 
additional 2.7 billion acres of land 
into cereal cultivation around the 
globe, it would result in greatly 
increased soil erosion, loss of forests 
and grasslands, and destruction of 
wildlife habitats with the resultant 
extinction of many more animal and 
plant species. 

Over the past 40 years, we owe a 
debt of gratitude to the environ- 
mental movement in industrialized 
nations, which has led to legislation 
to improve air and water quality, pre- 
serve wildlife, control toxic waste disposal, protect soils, 
and reduce the loss of biodiversity. Safeguarding the land, 
water, and atmospheric resource base of our planet is clear- 
ly central to presening our quality of life and the long-term 
survival of humankind. In looking to the future, however, 
our ecological impulses must be grounded in rationality. 
Logic — based on scientific data, not sentiment — will best 
serve the interests of nature and humankind. 

The use of high-yield production technology — with its 
consequent savings in land — has done much to protect the 
environment. This benefit is rarely acknowledged by envi- 
ronmental action organizations and little understood by 
urban populations. Technology is not the enemy of the 
environment; poverty is. 

Freedom and Justice for All 

Massive inequities continue today, despite our technolog- 
ical power to ensure food security for all who come into 
this world. Currently, more than one billion people in the 
industrialized world enjoy a standard of living that was 
unimaginable — even in the fondest dreams — of their 
grandparents and great-grandparents. Unfortunately, 
nearly one billion people remain illiterate, malnourished, 
hungry, ill, poverty-stricken, and without hope. Another 
two to three billion live outside formal economic systems, 
in varying degrees of poverty and want. These environ- 
ments of human misery and hopelessness are fertile beds 
for sowing and cultivating seeds of terrorism, which poses 
a serious threat to civilization and the future well being of 
humankind everywhere. 

I urge you not to close your eyes and hearts to the less 
fortunate, especially the hundreds of millions of people 
who begin and end each day hungry. These injustices must 
be lessened in the decades ahead. Remember, compassion 
is the greatest of all human virtues. 

Scientists in medicine today confront an explosion of 
new technology, problems in the delivery of health care, 
and the prospects of bioterrorism. In your role as healers 
you will need to maintain a strong personal commitment to 
professionalism and lifelong learning, to the welfare of your 
patients, and to the collective effort to improve the health 
care system for the welfare of society. 

I encourage you to apply yourselves to the fullest and 
to adhere to the highest levels of professionalism. Never be 
satisfied with the status quo or mediocrity; instead, reach 
for the stars. Although you can never touch one, if you 
stretch yourself, you will get a 
little Stardust on your hands. 
With this as a catalyst, you will 
be surprised at what you can 
achieve for yourself, your family, 
your community, your nation, 
and indeed, the world. ■ 

Norman E. Borlaug, PhD, received 
the 1970 Nofcel Peace Prize for his 
scientific and humanitarian efforts 
to end world hunger. 




A new HMS graduate offers lighthearted insights and heartfelt 
encouragements, by ANDREW DAUBER 


my fellow doctors? — let me be the 
umpteenth person today to congratu- 
late you, but perhaps the first to say 
"Mazel tov." ■ Since I suspect I will 
never win an Oscar, please indulge me 
a moment of personal thanks. When I 
was in fourth grade, I complained to my 
parents that my teacher was too hard 
and I wanted to switch to an easier class. They looked at 
me and said, "Andrew, go do your homework." Thank you, 
Mom and Dad, for your constant encouragement and 
support throughout these past 20 years of school. I would 
also like to thank my wife, Sara, for enduring many minutes 

of seeing spots while I learned to use an ophthalmoscope, 
endless hours of medical talk, and numerous evenings 
when I fell asleep over dinner. 

It is hard to recall what we were like before medical 
school. I remember during anatomy tutorial in first year 
asking, "What's the difference between 'ventral' and 'dor- 
sal' and 'front' and 'back'?" My tutor answered, "The only 
difference is that the patient doesn't know what 'ventral' 
and 'dorsal' mean." Neither did I at the time, but now med- 

ical lingo flows from my lips. I can spell 
"atelectasis" and "graphesthesia" in my 
sleep. I know a million eponyms such as 
von Braun-Fernwald's sign. Never heard 
of it? Here's a hint — it's the same as 
Piskacek's sign. Still no luck? Don't worry; I 
found it on my PalmPilot while writing this 
speech. It means asymmetry of the uterus 
with a well-defined prominence of the 
cornu, due to implantation near one of the 
cornua. Amazingly, in four short years, we 
have been transformed from Average Joe to 
Joe Millionaire (in debt), MD. 

The best part of my time at Harvard 
Medical School was getting to know my 
classmates. I don't know about you, but I 
find the idea of starting internship in a few 
weeks terrifying. I am thankful that we are 
all taking this next step together — except, 
of course, for our MD-PhD friends, whom 
we will be happy to see back on the wards 
just in time for us to be their attendings. 

I am also glad that we are all going into different fields. 
I like to think of it as a free consult service. If I ever need 
help interpreting a CT scan or MRI, no matter what city I 
end up practicing in, one of you future — is it 50? — radiol- 
ogists will be there to help me. As for my personal health, 
I know that my skin and eyes will be well taken care of, 
but God forbid I should ever need surgery — I may actually 
have to turn to a Hopkins graduate. 





I want to pass along a few secrets I 
learned in medical school. (For all of you 
out there who are not physicians, please 
don't tell your doctors that I revealed 
these tricks of the trade.) When a patient 
questions how long any given symptom 
will last — such as "Doc, when will my 
back pain go away?" or "Doc, how long 
am I going to have this cough?" — the 
answer is always "two to four weeks," 
unless you're in pediatrics, in which case 
the answer is "one to two weeks" 
because kids get better faster 

If a patient describes a complex of 
symptoms that, despite your encyclope- 
dic knowledge of pathophysiology, you 
simply cannot explain, look wise, nod, 
and say, "We see this, we see this." Alternatively, if the 
patient is academically minded, just push up your glasses 
and mumble something about a case report in the litera 
ture. Ah, the famed medical literature! It works every time. 

Here's the serious part. During third year, one of our class- 
mates said, "Andrew, you know what's great about HMS stu- 
dents? They ask important questions, the really big ones that 
matter." I couldn't agree more. I am continually inspired not 
only by your penetrating questions but also by your desire to 
find the answers to those questions and to create solutions 
when none exist. Through my years at HMS, I have been 
touched by all of your passions and dreams; they have infused 
me with a drive always to try to accomplish more. 

Whether your dream is to open a world-class cancer 
center in Puerto Rico, to ensure universal access to health 
care, to figure out how the inner workings of the brain 
control our ability to develop language, or to eradicate 
measles, here is my message to you: Keep striving to reach 
those goals. Harvard will open many doors for us in the 
future, but it is up to us to walk through those doors. So, 
my fellow graduates, the Class of 2004, as the great Aero- 
smith once sang, "Dream on, dream on, dream until your 
dreams come true." ■ 

Andrew Dauber '04 is a resident in pediatrics at Children's Hospital 
in Boston. 




A young physician offers a gracious prescription for 
how to practice medicine, by MARKELLA ZANNI 


rotations, I struggled to understand what 
the doctors around me were saying. I was, at 
the time, used to speaking in full sentences 
made up of honest-to-goodness English 
words. Abbreviations such as "S.O.B." — for 
shortness of breath — still struck me as 
profane. With the aid of reference books, 
though, I, too, picked up medical-speak. 
Acronyms and technical terms rolled, almost reflexively, 
off my tongue. The change in my manner crept up on me. 
Were it not for one striking patient encounter, I might 
not have noticed it at all. ■ I met Edna in July, toward the 
end of my medical sub-internship. She was in her late 

eighties, frail and soft-spoken, with warm, inquisitive 
eyes. A series of fainting spells had brought her to 
the hospital. 

After learning all I could about her problem, I presented 
her case to my team. I was goal oriented, intent on crafting 
and executing a thoughtful plan. "Did you ask about her 
end-of-life preferences?" one of the residents inquired. I 
swallowed hard. This was something I hadn't done. Ever. 

"Not yet," I said. "Not yet, but I will." 

That afternoon, I stopped by Edna's 
room and sat down on the edge of her bed. 
We chatted for a while. She reached out 
a wrinkled hand and rested it on mine. 
Taking this gesture as my cue, I cleared my 
throat. "Last night," I said, "when we first 
met, I forgot to ask you something." She 
cocked her head to one side and looked 
expectantly at me. 

I then gave Edna what I considered to be 
a sensitive monologue about advance 
directives, but she didn't seem to catch my 
drift. Finally, I decided to put the question 
more bluntly. "We certainly hope it won't 
come to this," I said, "but assuming your 
heart were to stop beating, would you 
want us to shock you?" 

Edna bit her bottom lip. "Shock me? At 
my age? What could you possibly say?" 

In my interactions with Edna, I had 
focused on what I needed to accomplish, 
without much reflection on the stxk with 
which I would accomplish it. 

As we prepare to graduate, it's natural for us to look ahead 
to what we as individuals will next achieve. These kinds of 
considerations constitute our visions of ourselves and our 
places in the world. No one would deny the importance of 
vision. More easily overlooked is the manner in which we 
daily conduct ourselves, or our style. I would like to give 
some thought to vision and style, taking a moment to 
observe what happens when the two come together. 


First, vision. Albert Schweitzer, the humanitarian 
physician and philosopher, developed the idea that our 
spirit, or inner flame, is often kindled at the most auspi 
cious time by an encounter with another human being. 
What kinds of encounters inspire? Different kinds, 
depending on your experiences and the way in which 
you've processed them. 

Consider your own track record. When in your graduate- 
school career — in your life — did you get goose bumps' 
When did you think, I need to do something about this 
situation? Or, I need to collaborate with this person? 
When did you experience that feeling of urgency, or neces- 
sity, or maybe even destiny? 

Once you've identified this kind of encounter, it's easy 
enough to let it guide you. To the question "where should 
I place myself?" you can answer: I should place myself in 
an environment where I Feel inspired to contribute. This 
may be a private practice in Porter Square. A walk- in 
clinic in Port au Prince. A policy think tank in Baltimore. 
A research lab in Brussels. You're the only one who can 
say for sure. You're the only one who can define your 
personal vision. 

In the process of realizing your personal vision, style 
comes into play. How will you interact with your patients? 
With what attitude will you conduct research in public- 
policy or basic science? I would argue that the foundation 
of style is kindness. In the setting of clinical medicine, 
kindness means working to understand your patients' feel- 
ings, considering their questions, or even holding their 
hands if that's what you sense they need to sustain a sense 
of dignity and hope. 

But there's more to style than kindness. There's that flair 
we may tend to reserve for our lives outside medicine. That 
ability to write poems, to compose folk and rock songs, to = 
choreograph African dances, to eat fire, to shred phonebooks. I 

Ry letting flair seep back into our professional lives, we 
will accomplish a couple of goals. We will connect more 
meaningfully with our patients, who, after all, have inter 
ests outside their aches and pains and temperature curves. 
And at the same time, we will — through our stamp, our 
style — indirectly pay tribute to those who have influenced 
us along the way: family members, teachers, mentors, 
patients, and. of course, that remarkably talented and 
diverse group we call classmates and friends. 

You may think it's a tall order to define your vision and 
realize it with style. But the beauty is that giving in this 
way will make you feel good because people will recipro 
cate. Patients and colleagues — those to whom you've 
extended yourself — will laugh at your silly jokes, send you 
postcards from Maui, or remember you in their prayers. 
They will help you appreciate the joys in this life. 

In my years at Harvard Medical School, I've been 
trained to emphasize a few key points in every talk. If 
asked to boil my speech down to its essence, I would say 
this: Think big, be yourself, and find joy. Or, vision plus 
style equals fulfillment. 

\ly patient, Edna, with her more than 80 years of life 
experience, might have been able to tell me as much. No 
real shock there. ■ 

Markella Zanni '04 is a resident m internal medicine at Brigham and 
Women's Hospital. 






April Wang Armstrong 

Richard C. Cabot Prize for the best 
i^ paper on medical education or 

medical history, for her contribution to 
the textbook Principles of Pharmacology: 
The Pathophysiologic Basis of Drug 

Ehrin Johnson Armstrong, 

magna cum laude 

VECT-NFATc 1 Signaling in Heart Valve 
Endothelium Implications for Heart 
Valve Development and Maintenance 

Supinda Bunyavanich 

Rose Seegal Prize for the best paper 
on the relation of the medical profes- 
sion to the community: (1) The Impact 
of Climate Change on Child Health; 

(2) U.S. Public Health Leaders Shift 
Toward a New Paradigm of Global Health 

Ronald Ching-Yun Chen, 

cum laude 

Developmental Therapeutic 
Strategies for UCN-0 1 

Jeffrey Hyo Chung, 

magna cum laude 

Cloning of a Novel ROBO Molecule 
(zfROB04) Essential for Neuronal and 
Vascular Development in Zebrafish 

Sandeep Robert Datta 

Leon Reznick Memorial Prize for 
excellence and accomplishment in 
research: (1) Akt Phosphorylation of 
BAD Couples Survival Signals to the 



Today, you stand before family friends, teachers, and colleagues, ready to become 
physicians and dentists. For two thousand five hundred years, since the time of Hip- 
pocrates, doctors have taken an oath to affirm a commitment to their profession. This 
oath has served as both a tribute to their teachers and as a contract with their community. 
In this spirit, the Class of 2004 has created an oath that draws upon elements of oaths 
both recent and ancient. I now invite you, as a class, to share in this tradition and to 
articulate the ideals and principles that willguideyou in theyears ahead. 


I solemnly pledge to consecrate my life to the service of humanity: 

To my patients: 

I vow to care for those in need and strive to alleviate suffering. 

I will empower my patients to make sound decisions for their health and 

I will respect and allow considerations of religion, race, and social 

situation to inform and refine my duties as a doctor. 
I will remember that medicine is an ever-changing art and science in which 

sympathy, honesty, and understanding create the trust whereby the 

surgeon's knife and the chemist's drug have utility. 
I will remember that I do not treat a disease or a number, but a human 

being, whose illness will affect the world they touch. 
1 will respect my patients' dignity and autonomy, both in their living and 

in their dying. 
I will honor and protect the confidences entrusted to me. 

To my community: 

I will maintain the utmost respect for human life and will not use my 

medical knowledge contrary to the laws of humanity. 
I dedicate all my knowledge and strength to the health of humankind 

and the treatment and prevention of disease. 
I will serve as an educator to my community. 
I will address the social and environmental problems that impact 

the health of my patients. 
I will support efforts to extend health care to everyone. 

To my colleagues: 

I will respect the hard-won scientific gains of those doctors in whose steps 

1 walk and gladly share such knowledge with those who arc to follow. 
I will uphold the example and wisdom of my mentors and build upon their 

teachings to advance our field. 
I will work in diligent and honest collaboration with my fellow 

practitioners and health care providers to uphold the highest standards 

of patient care. 
1 will teach and advance the art and science of medicine with honesty, 

kindness, and dignity. 

To myself: 

I will work to constantly perfect my medical knowledge and clinical skills 

and strive to advance the science and practice of medicine. 
1 will recognize my limitations and will seek help when needed. 
I will acknowledge my mistakes so that I may learn from them. 
I will maintain my own health and well-being, and the well-being of those 

close to me, so that I may best uphold my responsibilities. 
1 will always act to preserve the finest traditions of my calling so that 

I may long experience the joy of healing 
I will ensure that, above all, the health of my patients is my first concern. 

With the support of family and friends, peers and mentors, I pledge to fulfill 
this oath to the best of my ability and judgment, as I dedicate myself to the 
art and practice of medicine. 




Cell-Intrinsic Death Machinery; (2) Survival 
Factor-Mediated BAD Phosphorylation 
Raises the Mitochondrial Threshold for 
Apoptosis; and other publications 

James E. De La Torre 

Society for Academic Emergency 
Medicine Excellence in Emergency Medi- 
cine Award to a senior medical student 
who has demonstrated excellence in the 
specialty of emergency medicine 

Sumeet Garg, cum laude 
Langerhans Cell Histiocytosis of the 
Spine in Children 

Katharine Creskoff Garvey 

The New England Pediatric Society Prize 
to the senior who, in the opinion of peers 
and faculty, best exemplifies those quali- 
ties one looks for in a pediatrician 

Suzanne Goh, cum laude 
Altering the Natural History of 
Cerebral Tuberous Sclerosis: Frontiers 
in Prognosis and Management 

Brian Barkley Graham, cum laude 
A Retrospective Study of Pediatric 
Tracheal Surgery 

Anna Greka, magna cum laude 
Henry Asbury Christian Award for notable 
scholarship in studies or research: TRPC5 
Is a Regulator of Hippocampal Neurite 
Length and Growth Cone Morphology 

Jamal Cinque Harris, cum laude 
A Qualitative Study of HIV Testing Beliefs, 
Attitudes, and Behaviors of Black and 
Latino Males Ages 15-23 in the Boston 
Metropolitan Area 

Renee Yuen-Jan Hsia 

Bemy Jelin '91 Prize to that senior who 
most demonstrates overall academic 
excellence with a career interest in pedi- 
atrics, oncology, international health, or 

Jerrilyn Denise Jones 
The Community Service Award to 
the senior who has done the most to 
exemplify and/or promote the spirit 
and practice of community service 

Ravi Shanker Kamath, 

magna cum laude 

Functional Genomic Analysis of RNA Inter- 
ference in C. Elegans; James Tolbert Ship- 
ley Prize for excellence and accomplish- 
ment in research: (1) Systematic 
Functional Analysis of the Caenorhabditis 
Elegans Genome Using RNAi; (2) Func- 
tional Genomic Analysis of C. Elegans 

Chromosome I by Systematic RNA 
Interference; and other publications 

Vikram Sheel Kumar, 

magna cum laude 

The Design and Testing of a Personal 
Health System to Motivate Adherence 
to Intensive Diabetes Management 

Aya Kuribayashi, Liyun Li, Alden 
Joseph McDonald III, Amina Ann 
Porter, and Coleen S. Sabatini 

The Multiculturalism Award to the senior in 
each Academic Society who has done the 
most to exemplify and/or promote the spirit 
and practice of multiculturalism and diversity 

Julie Haya Levison 

The Leonard Tow Humanism in Medicine 
Award presented by The Arnold P. Gold 
Foundation to a graduating medical 
student who consistently demonstrates 
compassion and empathy in the delivery 
of care to patients 

Liyun Li, cum laude 
Identification of Molecular Controls over 
Differentiation of Neural Precursors into 
Cortical Projection Neurons (CPNj 

Kenway Louie, cum laude 
Hippocampal Mnemonic Activity and the 
Interaction Between Rapid Eye Movement 
and Slow Wave Sleep; Dr. Sirgay Sanger 
Award for excellence and accomplishment 
in research, clinical investigation, or schol- 
arship in psychiatry: Temporally Structured 
Replay of Awake Hippocampal Ensemble 
Activity During Rapid Eye Movement Sleep 

Stephanie Misono 

Role of the Inwardly-Rectifying 
Potassium Channel Kir2. I in Mammalian 
Craniofacial Development 

Tami Tiamfook Morgan, cum laude 
Differences in Reproductive Hormonal 
Dynamics Between African-American 
and Caucasian Women 

Paul Linh Nguyen 

The Gerald S. Foster Award in recognition 
of contributions to the student body by 
virtue of serving on a student-faculty 
committee including but not limited to 
the Committee on Admission 

Yvonne Ou, magna cum laude 
The Endothelial Cell Nucleus as a 

Sail ie Robey Permar, magna cum laude 
Pathogenesis of Measles Virus Infection in 
Simian Immunodeficiency Virus-Infected, 
Measles Virus-Vaccinated Rhesus M\onkeys; 

\ . 

PASTEUR Award presented to a graduating 
medical student whose work best exempli- 
fies clinical investigation that has resulted 
in a published paper or one accepted for 
publication: (1) Increased Thymic Output 
During Acute Measles Virus Infection; 
(2) Prolonged Measles Virus Shedding in 
Human Immunodeficiency Virus-Infected 
Children, Detected by Reverse Transcrip- 
tase-Polymerase Chain Reaction 

Ngoc Thi Phan, cum laude 
Examining the Antigenicity of Modified 
HIV- 1 Envelope Glycoproteins 

Eric Scott Rosenthal 

Kurt Isselbacher Prize to the senior 
demonstrating humanitarian values and 
dedication to science 

Joan Joonsun Ryoo, cum laude 
Transcriptional Changes Induced by 
PS-34 I Treatment of Co-cultured Multiple 
Myeloma and Bone Marrow Stromal Cells 

Lucy Q. Shen, cum laude 
Exploring Rosiglitazone-Mediated 
Angiogenesis Inhibition: From the 
Lab Bench to the Clinics 

Derek Matthew Steinbacher, 

cum laude 

Mandibular Advancement by Distraction 
Osteogenesis for Tracheostomy-Dependent 
Children with Severe Micrognathia 

Mary Elizabeth Layfield Thorndike 

Robert H. Ebert Primary Care 
Achievement Award for excellence 
and outstanding accomplishments in 
the field of primary care medicine 

David Tsai Ting, magna cum laude 
Optimization of HoxB4 Expression in 
Embryonic Stem Cells in the Development 
of Hematopoietic Stem Cells 

Ryan Bernard Turner 

Henry Asbury Christian Award for notable 
scholarship in studies or research: (1) 
Structural Elements That Govern the Sub- 
strate Specificity of the Clot-Dissolving 
Enzyme Plasmin; (2) Coevolutionary 
Patterns in Plasminogen Activation 







A leader in medicine offers a proposal to help doctors, patients, and hospital 






errors and costs. To analyze and prevent errors, we have taken a systems 
approach. Not so with health care costs. The sad fact is that efforts toward 
health care reform have accomplished little. Critics continue to publish 
reports on how bad things are, and the government repeats old approaches, 
hoping for consequences that will, somehow, differ this time around. ■ It 
seems to me — and to Jack Cook, a colleague knowledgeable about health 
care financing — that with costs, a systems approach is also called for. 
Granted, systems do exist in health care today — conventional Medicare is 
a system, as are strict staff model HMOs such as Kaiser Permanente — but 
each has its limitations. ■ Despite the good intentions of physicians and 

navigate the health care crisis, by MITCHELL T. RABKIN 



hospitals, neither fee-for-service nor managed 
care has held down costs effectively, largely, we 
believe, because of a lack of incentives guiding 
players in the system to make choices that are 
both cost-effective and therapeutic. Now, health 
care should not be a commodity delivered through 
the operation of market forces. Yet certain market 
incentives can be used to foster the effective and 
cost- efficient delivery of services. Payment sys- 
tems, however, tend neither to offer doctors 
incentives to use resources prudently nor to 
encourage patients to be wiser purchasers. 

The challenge is to keep costs at a reasonable level yet 
provide appropriate care and coverage. The goals include 
the prevention of illness, the promotion of health, the use of 
effective medical information technology and evidence- 
based medicine, and the moderation of costs. The absence 
of effective incentives not only fails to temper costs, but it 
can also undermine quality of care. Beta-blockers, for exam- 
ple, are widely underused as therapy after heart attacks. 

Systems of health care delivery and payment today carry 
mixed messages. While fee-for-service offers practitioners 
no compelling incentives to control costs, the patient 
perceives an advantage in that doctors and patients can 
make decisions about clinical care without intrusion by 
insurers. This is the dominant Medicare model. 

By contrast, the staff model HMO, exemplified by Kaiser 
Permanente, employs a budget in which fee-for-service 
inflationary incentives are neutralized through salary- 
based payment. But the strict HMO approach is not for 
everyone, restricting, as it does, physician choice and con- 
fining services within a closed network. 

Here's the dilemma: Can we develop a system of good 
care that enjoys both the advantages of fee-for-service and 
the organizational and payment strengths of Kaiser? 

For Humpty Dumpty to be put back together again, 
consider these principles: cost control is not possible 
without a budget; the budget must provide fair payment 
for the services covered; medical care decisions should be 
made by physicians and their patients based on the best 
scientific evidence available being applied to the care of 
individual patients; economic incentives must be meaning- 
ful for all involved to meet budget targets, quality-of-care 
standards, and patient satisfaction; and incentives should 
be comparable across the spectrum of payers. 

The challenge is to move from principles to practice 
while allowing the doctor and the patient the freedom to 

make clinical decisions together and retaining the patient's 
right to change doctors or hospitals if dissatisfied with 
performance. Could we develop incentives to influence the 
patient, the primary care physician, the referral specialist, 
the hospital, and the insurer? 

All the King's Horses 

We've labeled our idea "Balanced Incentives for Health." 
Here's how it would affect the stakeholders: 

The patient. The patient would choose a primary care physi- 
cian (PCP) who would be responsible for providing or arrang- 
ing for the patient's covered services. As with other insurance 
plans, the patient — and employer, in many instances — would 
pay the insurer a monthly premium. The incentive to follow 
the PCP's recommendations is that, by doing so, the patient 
would pay no additional out-of-pocket deductibles or repay- 
ments for services delivered or authorized by the PCP. The 
patient could also self-refer to any physician at any time 
without prior authorization by the PCP or the insurer, but 
deductibles and copayments would then apply. 

The primary care physician. Insurers would foster the volun- 
tary formation of PCP groups — perhaps ten to twenty 
PCPs — who would be paid on a per-member-per-month 
basis, risk- adjusted, taking into account issues such as the 
age, gender, and health of enrollees. That baseline payment 
would be adjusted in relation to three indices: the group's 
financial performance, the results of patient satisfaction 
studies, and the evaluation of services in terms of accepted 
quality criteria. 

A meaningful additional payment in relation to favorable 
overall performance according to these criteria would cre- 
ate a further incentive for the PCP. The satisfied patient 
would tend to stick with that doctor — and commend that 
doctor to others — while the unhappy patient would switch 





Co another. This would give the patient a choice and the 
physician an opportunity to be rewarded tor performance. 

The referral specialist. The payment to the primary physi 
cian group would include money the PCP would pay for 
specialty consultations, emergency department visits, and 
all other covered services except inpatient hospital care. 
Specialty care would be monitored by the same informa- 
tion technology that watches the PCP's usage, budget, and 
criteria for quality When the patient's PCP orders the 
referral, the patient would pay nothing out of pocket. 
Should the patient select another specialist, the deductible 
and copayment would apply Paying referred specialists 
out of the total capitated payment, the PCP would lean 
toward those who arc careful with costs but also practice 
with high quality and patient satisfaction. Specialists not 
doing so would be avoided. 

The hospital. Payment tor hospital care would come from a 
ditterent component of the insurer's premium rev enue. and the 
basis ol hospital payment would be similar to that ol \ Icdicare 
Part A, where payment levels relate to diagnoses and compli 
eating issues. While the PCP groups would not be at risk tor 
the actual cost ol anv hospitalization, their capitation pay 
ments would include an additional incentive targeted toward 
a pre established standard tor hospital days or admissions 
related to the risk of their patient population, i hat w ould curb 
marginally indicated hospitalization, where the burden ot cost 
is shitted to the hospital rather than remaining w ith the PCP. 

And All the King's Men 

But this scenario carries two big "its " First, the arrangement 
could work only it fairly priced and paid. Second, the ke\ to 
reform would lie in Medicare's leading the charge. Given its 
dominance, an unresponsive Medicare would subvert any 
ettort tor reform in the private seaor. Today's Medicare w ill 
remain part ot the problem it it Fails to lead in the solution 
But, by using its enormous eontracting power to implement 
this new paradigm. Medicare could create a balanced incen 
fives option more attractive than its current offerings \nd 
the private sector would likely follow 

To the doubters among you, consider these questions 
Who is happy about health care today? And w hat new and 
workable ideas are forthcoming 

The public and employers are pressed to pay more and 
more, physicians and patients arc unhappy with the way care 
is delivered, academicians arc concerned about the impact on 
teaching and training, costs continue to mount, quality issues 

persist, and the number of people uninsured remains a 
national scandal. The date by which Medicare will run out of 
money has recently been advanced by seven years, and the 
\ leclicare drug legislation is now estimated to rise 25 percent 
over what was said to be the definitive cost. How much 
closer to crisis must the nation slide before action is taken? 

Balanced Incentives for Health calls for significant change. 
Patients would have a range of choices with graded financial 
responsibility. PCPs would gain a resumption ot the profes 
sional responsibility of managing clinical care in return for a 
fair system of prepaid capitation with meaningful incentives. 
PCPs and specialists alike would compete by providing high 
quality care, using resources prudently, and satisfying their 
patients. Employers would enjoy a tempering of costs with 
support of care quality and workers' health. And insurers 
would get relict from the inappropriate responsibilities ol 
clinical management in return lor more effective cost control. 

Balanced Incentives tor I lealth is a workable new paradigm 
tor \ ledic are and one that could trigger comparable movement 
in the private sector. And tor go\ ernments, this paradigm could 
lead toward universal coverage 

To achieve success, Balanced incentives for Health would 
require both fair payment and meaningful incentives. Equal 
1\ c rit ical w ould be a sound information management system 
\s a nation we lace this choice we can develop a rational sys 
tern — one that w e tund fairly by using locused market incen 
rives lor prudent commitment ot resources and one that 
delivers high L|iialitv ^are and satisfies the expectations of 
patients — or we can continue our existing non system, which 
restricts and underfunds care and vet will break the hank. 

The question is Arc physicians, the public, insurers, busi- 
nesses, gov eminent . and the various health care interest groups 
sufficiently fed up with the status quo and sufficiently con 
cerned about the future to move beyond declaring, "Some 
thing must be done!"? The essence of futility is to continue 
doing the same thing and expect 
different results It is time to make 
health care in the United States 
the benefit it should be tor all. ■ 

Mitchell T Rabkin '55 is a professor of 
medicine at HMS, ( 1:0 emeritus at 

Beth Israel Hospital and Carcgroup, 
and an institute scholar at the Carl \. 
Shapiro Institute for Education and 
Research at HMS and Beth Israel 
Deaconess Medical Center 



A physician argues that national health 
insurance will provide good care and a 
far more equitable distribution of resources. 

by Steffie Woolhandler 


major but quickly found the discipline 
too dry; we used to joke that an econ- 
omist was someone who lacked the 
personality to become an accountant. 
So I made what I thought was a 180- 
degree turn and decided to become 
what I called "a people's doctor." I was going to take care of 
poor people and the oppressed, senior citizens and chil- 
dren. I was going to be out there delivering hands-on care. 
But I hadn't been in medicine for long before I realized 
that financing gets in the way of delivering care. We may 
have great doctors, great hospitals, and great research but, 
over and over, health care financing impedes our work. 

Sigmund Freud pioneered the idea that things aren't 
always what they seem. As an internist, I would para- 
phrase Freud as follows: everything in human life is sex, 
except sex — which is aggression. But I would go a step 
further and say that in the public health and policy field, 
everything about human life is health, except for health 
care — which is finance. So I want to touch on health care 
financing — both how the system is broken in this country 
and how we as physicians can help fix that system to 
benefit our patients. 

Todays 44 million uninsured Americans 
represent only the tip of the iceberg; many 
people with only partial insurance still carit 
get all the care they need. That's one way to 
view the current health care crisis. The other 
way to look at it is in terms of the rising 
cost of health care. This year it's expected 
to increase about 8 percent, after 9- and 10- 
percent jumps in pre\ious years. And this 
means that the health care crisis will not 
disappear. We are in an unstable system, at 
least partly because of what these rising 
health care costs mean to employers. 

I was recently a visiting professor at 
Mc Master University in Ontario. To get 
there, you have to drive about 40 miles 
south from Toronto to the city of Hamil- 
ton. En route, you pass a field where, as far 
as the eye can see, there's nothing but Ford 
Freestars. Up the hills, down the hills, in 
the valleys: Ford Freestars. It turns out 
that every Ford Freestar in North America is now manu- 
factured in Ontario. We hear a great deal about the two 
million U.S. jobs lost to China, but we hear less about U.S. 
jobs migrating to places like Canada, where employee 
benefit costs related to health care are much lower. For 
employers in the United States, employee benefit costs 
represent 8 percent of payroll; but in Canada they're only 
a fraction of that. So we have an untenable situation in 
this country with rising employee benefit costs interfering 
with the competitiveness of U.S. firms. 





h 1 ri 1 1 k 



d il 1 »1 1 
1 kl 111 1 






During the past few years, I've been doing research with 
colleagues at Harvard Law School, in which we inter 
viewed people in five federal bankruptcy courts around 
the nation to find out whether there were medical con- 
tributors to their bankruptcies. And we discovered that 
medical bills contribute to 40 to 55 percent of all bank- 
ruptcies in the United States, devastating literally mil- 
lions of people every year. The transcripts of our phone 
interviews with these people reveal dreadful stories. 
When they became sick or injured, they lost their jobs, 
their health insurance, their retirement savings, their kids' 
college funds, their homes — all because of our broken 
health care financing system. 

The other side of this story is the underin 
sured, many of them senior citizens. By the 
year 2025, the average senior citizen will 
have to devote 35 percent of his or her 
income to health care, despite the existence 
of Medicare. Now that's only if we continue 
with the current Medicare program, which 
provides defined benefits, such as a certain 
number of hospital days. 

If we were to enact the Republican Party 
proposal advocated by President Bush, we 
would replace employer- and government- 
promised benefits with vouchers, which 
recipients could supplement with their 
own money to purchase health insurance. If 
we adopt such a model, by 2025, the average 
senior citizen will be spending 43 percent of his 
or her income on health care, despite the exis- 
tence of Medicare. These voucher-like payments 
are a key policy initiative right now in 
Washington and in the business community. 
They are, in short, a way to reduce the total 
amount of insurance available to patients. 

Another side of this crisis is the profound 
bureaucratization of health care. We've wit- 
nessed a 2,500 percent increase in the num- 
ber of health administrators over the past few 
decades. The business orientation in medicine is 
eroding patients' coverage. And it's taking away many 
of the elements that physicians find rewarding about medi- 
cine, including our ability to take good care of patients. 

If we were to compare total health spending in the 
United States with that in other developed nations, we 
would find an interesting dichotomy. U.S. health spending 
can be split into two categories. The first is private spend- 

ing, and the second is the tax- funded part of health spend- 
ing — not just Medicare and Medicaid, but also the bene- 
fits of government workers. The second category also 
includes the so-called tax-subsidy to private health insur- 
ance, the amount of money lost to the Treasury because 
health benefits are not taxable as income. 

Sixty percent of U.S. health care is tax funded. And it 
turns out that the tax-supported share of health care in the 
United States already exceeds the total health expenditure 
in every other nation in the world — and yet the United 
States lags three years behind the best-developed nations 
in terms of life expectancy. And then we take an average of 
another $1,400 out of our individual pockets for private 
expenditures. Clearly, the United States already 
has the money within the health care system to 
provide excellent health care for everyone. 
A part of the wasted resources is adminis- 
trative costs, which we quantified in a study 
published last summer in the New England 
Journal of Medicine. We found that the health 
administrative cost difference in the United 
States relative to Canada is more than S1,000 
per capita. To frame this issue in the context of 
hospitals, Boston's Brigham and Women's 
Hospital employs approximately 300 people 
in its billing department; Toronto General 
Hospital, a similar institution, has fewer 
than ten. That's because Toronto General 
Hospital receives its entire budget on a 
lump-sum basis, negotiated every year, with 
one-twelfth of the money deposited into its 
bank account every month. This provides huge 
administrative savings and allows the hospital 
and its doctors to focus on care. 

In a recent New England Journal of Medicine 
article, the authors of one study divided the 
United States into health care spending 
quintiles. They found that some of the best 
health care in the country is the cheapest, on a 
par with rates in Canada. Minnesota and Wash- 
ington State, for example, teach us that we can 
spend less and still have excellent quality. 
Now, I'm from Louisiana, near Cameron Parish, a poor 
area that nonetheless has the highest quintile of Medicare 
spending. Yet there's no way you can convince me that 
high-spending Cameron Parish has better medical care 
than the low-spending areas of Minnesota and Canada. In 
response to a claim that Cameron Parish gets good value 



for its health care dollar, we Louisianans would say, "That 
dog won't hunt." 

In fact, the authors of this study found, through com- 
plex statistical analysis, that, in the United States, the less 
expensive areas have a better quality of care than the high 
spending areas. And their findings are consistent with 
those of other research. Most studies are showing that 
Canadians receive a quality of care similar to that of 
insured Americans and, obviously, much better than the 
aggregate quality available to the insured and uninsured in 
this country. 

But what about political support for universal coverage? 
An October 2003 poll asked the American public, "Would 
you prefer the current system of universal insurance, like 
Medicare, run by the government and financed by taxpay 
ers?" Sixty-two percent of the respondents endorsed 
national health insurance defined in that way. 

My own group. Physicians for a National Health Pro- 
gram, looked at physician opinion as well. We interviewed 
a random sample of Massachusetts physicians and pub 
lished their responses in the Archives of Internal Medicine. 
When asked which type of structure would offer the best 

health care to the greatest number of people for a fixed 
amount of money, 64 percent endorsed the idea of single 
payer national health insurance. 

But are physicians willing to go public with their 
endorsement of national health insurance? You bet they 
are. Published last summer in the Journal of the American 
Medical Association was a proposal for single-payer national 
health insurance that's universal and comprehensive. The 
proposal — which was endorsed by more than 13,000 U.S. 
physicians — called for simplified reimbursements, no 
copayments, and the elimination of investor ownership of 
HMOs and hospitals because such ownership raises costs 
and lowers quality, as established in a recent review in the 
Canadian Medical Association Journal. 

We physicians are calling for a system we've dubbed 
"Canada deluxe," a system with the administrative effi- 
ciency of Canada's national health insurance — and with the 
approximately 40 percent higher spending level that we 
are used to in the United States. And this proposal is pre- 
cisely what Physicians for a National Health Program is 
advocating: improved health planning, public account 
ability for quality and cost, and minimal bureaucracy. 

Many people, when they saw the JAMA article, with 
thousands of doctors calling for an increased government 
role, were shocked. And in fact, one editorial writer com- 
mented, "Physicians for a National Health Program? That's 
a little like Furriers for Animal Rights." Nonetheless, many 
doctors are linding that the current financing arrange 
ments are just not tenable and have joined with their 
patients in advocating for national health insurance. 

Now, because I like animal jokes, I'll end with one to 
emphasize that we can't expect better results with this crisis 
simply by doing the same thing over and over again. The story 
goes like this: Three elk hunters had hired a pilot to airlift 
them to a remote lake in Canada. When he dropped them off, 
the pilot said, "Now remember, it's a small plane. We can only 
bring back one elk." 

When the pilot returned a week later to pick them up, the 
guys were standing there with three elk. And they said, "Look, 
last year you told us the rule about only one elk. We offered to 
pay you double to take two elk on the plane, and you agreed. 
This year, we'll pay you triple to airlift out all three." 

The pilot thought it over, nodded, loaded the elk and the 
passengers, and took off, only to run into the top of some 
trees almost immediately. Luckily all on board survived, but 
they were injured and dazed. When one of the hunters 
finally gained consciousness, he asked, "Gee, where are we?" 
And one of his buddies replied, "Well, I'm not sure, but I 
think about 50 feet from where we crashed last year." 

I invite you to join with us in our quest for universal health 
coverage, so we won't just keep crashing year after year. ■ 

Steffic Wbolhandler, XID, is associate professor of medicine at HMS 
and Cambridge Hospital and co founder of Physicians for a National 
Health Program. 




as a private practitioner on the health 
care crisis, I didn't initially jump at the 
chance, though I had much to say. I was in 
the midst of the discovery phase of my first 
malpractice suit. My malpractice premium 
for the previous year had doubled. Our prac- 
tice's largest third-party payer had sent us a 
take-it-or-leave-it letter along with a drastically 
cut reimbursement schedule. My physical stamina and 
emotional commitment to obstetrics were in constant 
dispute about the wisdom of continuing to deliver babies. 
I was the embodiment of health care in crisis. 

When I finally agreed to take this opportunity on Alumni 
Day, I was pleased to have an outlet for the rage I felt toward 
the impediments to continuing my private practice. But as my 
rage cooled, I began to consider how the health care crisis was 
affecting the health of my daily practice, the health of my 
patients, and my own health. Unfortunately, my considera- 
tion yielded more questions than answers to the dilemma of 
how to keep the health in health care. 

How did I end up in this position anyway? How did I 
come to practice the specialty with one of the highest risks of 
malpractice actions and one of the highest liability insurance 
premiums? Why did I limit my practice to women, the less 
economically empowered half of the population? (The insur- 
ance companies' regard for women's health can be surmised 
by their tendency to reimburse many services that are pecu- 
liar to women at routinely lower rates than those for compa- 
rable services for men.) And whose idea of a joke was it when 
the decision was made that babies would not generally be 
born between nine in the morning and five in the afternoon? 

The simple answer: it was Harvard's 
fault. Surely my decision to pursue obstet- 
rics was not based on my medical school 
ob-gyn rotation, for it can be best described 
as one of singular experiences. I had seen 
exactly one patient with pre-eclampsia, one 
with a Caesarean section, and one with a 
twin delivery — and they were all the same 
patient. No, it was because someone at 
HMS had convinced me that I could enjoy 
all the aspects of internal medicine and 
surgery that I loved, that I could care for 
women throughout the seasons of their lives 
and add quality to those lives, and that I 
could practice preventive medicine — all 
through the ob-gyn specialty. 

Now you see my real reason for accept- 
ing this invitation: to revisit the scene of 
the crime; to consult with some of the play- 
ers who were there before, during, and after 
my decision was made; and to decide whether my obstetri- 
cal practice is still a workable proposition in the current 
state of crisis in litigation, liability insurance, reimburse- 
ment, and physician burnout. 

One need only visit the American College of Obstetri- 
cians and Gynecologists (ACOG) website to get an updat- 
ed estimate of the proportion of ob-gyns who will have 
malpractice actions brought against them during their 
careers; the number now hovers near 80 percent. We are 
indeed a high-risk specialty. A recent ACOG survey con- 
cluded that concern over medical liability has the largest 
negative impact on career satisfaction for ob-gyns. 

The solution for many of my colleagues has been to elim- 
inate obstetrics from their practices. Some have retired 
early or moved to other professions altogether. And these 
same concerns have contributed to an all-time low in the 
number of U.S. medical students applying for ob-gyn resi- 
dencies. These trends make the question of who will be 
delivering our babies a legitimate one indeed. 



An obstetrician delivers a tough assessment 
of the realities of a medical specialty in peril. 

by Vanessa Haygood 


Why the steady increase in malpractice claims? The rea- 
sons are myriad, but a recurring theme is unmet expecta- 
tions, a disconnect between what patients feel their doctors 
should have done for them and what their doctors have actu- 
ally done for them. So, are expectations too high, or is per- 
formance too low? I do know that the bar has been raised for 
what is considered acceptable in terms of an outcome for a 
baby, results from surgical procedures, and the ability of 
diagnostic tests to predict disease. 

At the same time, for each patient we encounter, doctors are 
now faced with having to gather, assimilate, and integrate 
more information into a plan of care, all in ever-decreasing 
lengths of time. In my specialty, this translates into much more 
complex obstetrical interviews and advice sessions as we try 
to ensure awareness of any medication intake, environmental 
exposure, or chronic habit that may affect the pregnancy. 

Next are the informed consent issues. Does each word of 
the informed consent conversation need to be documented to 
confirm that it was actually uttered? We recently spent near- 
ly six months revising our in-office consent form for vaginal 
birth after Caesarean section — better known as VBAC, a 
true four-letter word in obstetrics — to ensure that all risks 
had described to each patient are included, before 


defaulting to the "unforeseeable risks" clause. Again, are 
expectations too high, or is performance too low? The two do 
seem to be moving away from each other at breakneck speed, 
creating a chasm ripe for spawning malpractice actions. 

Other malpractice actions relate to the need for a patient 
who has suffered an injury to be able to pay for the medical 
care required to live with that injury. The current litigation 
system, an inefficient conduit for these resources, is often 
the only recourse a patient has for adequate assistance. I 
suspect many patients would favor a system that rapidly 
brought funds to help them meet their medical needs and 
replace lost earnings. I believe, perhaps naively, that fewer 
patients would feel the need to punish their doctors for 
their pain and suffering if those needs were met. 

Malpractice actions and malpractice premiums are direct- 
ly related — or are they? It is true that awards to plaintiffs, 
especially in obstetrics, have skyrocketed. Some suspect, 
however, that the rapid rise in liability insurance premi- 
ums is just as tightly linked to poor stock market perfor- 
mance and the resultant inability of the insurance companies 
to meet their fiduciary responsibilities to their shareholders. 

Whatever the cause, I've seen my insurance premiums 
take off like a wildfire in a drought. My dismay at having 

those premiums double in one year was dwarfed by the 
dread I felt as I tried to change carriers to seek better rates. 
That meant buying tail insurance, also known as prior acts 
coverage, priced at twice the premium of the previous year. 

How can such increases be funded? In private practice, 
our only source of revenue is seeing patients. So my only 
choices seemed to be decreasing the time spent with each 
patient or extending my current ten-hour office day. But 
when we added to our practice an adept certified physician 
assistant, an experienced nurse practitioner, and five certi- 
fied nurse-midwives, the numbers seemed workable again. 

That light at the end of the tunnel dimmed, though, when 
our managed- care contracts arrived, accompanied by new fee 
schedules. Those schedules have yet to increase even as much 
as staffing or supply expenses, and certainly never as much as 
malpractice insurance. Again, what could we do? See more 
patients? Drop the plan in question? Try to negotiate a fairer 
reimbursement schedule? A recent successful lawsuit against 
a large managed- care organization in North Carolina to end 
unfair physician reimbursement practices has brought at 
least one carrier back to the negotiation table. 

Medicine can be physically, intellectually, and emotion- 
ally challenging. Add a few more hours to the day and 
medicine becomes physically, intellectually, and emotion- 
ally demanding. Yet a few more hours transforms medicine 
into a tyrannical drain on all our sensibilities. Taking time 
to refuel is the only way I know to keep the challenges of 
medicine alluring. 

The refueling process takes a different form for each of us. I 
have been fortunate to find refueling stations in many places. 
They lie among my wise patients, my grateful patients, and 
sometimes even my sad, frightened, or angry patients, and the 
stories they share with me. My refueling depends on the 
moments I take to discover that the office and hospital staff 
are mothers, daughters, and dreamers just like me. 

And yes, in the wee hours of the morning when the nine- 
month journey has come to an end and a tiny being with all 
new possibilities makes an appearance, I find it hard to 
imagine that I won't keep doing this work. It's impossible to 
sum up how deeply I feel about what I do each day, or how 
the challenges we all face now affect that commitment. But 
I have realized that I am not yet ready to give up hope that 
health care can be made healthy. ■ 

Vanessa Haygood 78 practices obstetrics with Piedmont Healthcare 
for Women in Greensboro, North Carolina. 



One state's struggle to survive the medical malpractice crisis 

has left doctors, patients, and lawmakers searching for answers. 



wheels, craps tables, and one-armed 
bandits — has recently acquired noto- 
riety for another series of high -stakes 
wagers: some of the nation's most 
expensive malpractice premiums 
and the largest number of personal 
injury attorneys per capita. In 2002, Nevada drew national 
attention when, as a result of its malpractice insurance 
crisis, its only level one trauma center closed for ten days. 

Unfortunately, the problem that started in Vegas did not 
stay in Vegas; 19 other states have joined Nevada in its clas- 
sification by the American Medical Association as "in crisis." 
The crisis started when jury awards in Clark County, 
where Las Vegas resides, began to increase. In the mid- 
nineties, such awards remained stable in the $500,000 range 
for cumulative payout for all malpractice cases. But in 
1998 they began to rise steadily until they peaked at 

S21 million in 2001. In Nevada, a state with 
roughly 3,700 active physicians — more than 
2,400 of whom are in Clark County — there 
simply aren't enough insurance policies 
written to overcome payouts on that scale. 

And since insurance companies set their 
premiums on a regional or state basis, and 
they perceived Nevada juries to be operat- 
ing with a jackpot mentality, Nevada 
became a bad place to do business. When 
St. Paul, the leading insurer in Nevada, 
announced it was pulling out in 2002, the 
company insured 60 percent of all physi- 
cians in the state, including most of those 
in high-risk specialties. After the pullout, 
many doctors faced premium increases of 
100 to 400 percent. 

For some, the rise in premiums meant they could not make 
ends meet and had to retire early or leave the state. Our mal- 
practice problem had just become a crisis, one that took on a 
political angle when Nevada's commissioner of insurance 
called a hearing. Large numbers of us in the medical commu- 
nity closed our offices. We wore our white coats to the 
hearing to make a political statement and show our unity. 




H 111 ■ 1UI I 



Our presence at the hearing generated some media atten- 
tion, and the governor subsequently created a state-run 
insurance company to provide medical malpractice insur 
ance to doctors as a short-term solution. But we did not 
want the new insurance company to write high-priced poli- 
cies. We wanted Nevada's own version of a Medical Injury 
Compensation Reform Act (MICRA), which proved to be 
a miracle cure for California's malpractice woes in the 1970s. 

Among other provisions, MICRA dictated a $250,000 
hard cap on non-economic damages per incident and limit- 
ed attorneys' fees. Doctors in high-risk specialties believed 
that MICRA would bring them affordable premiums. And 
those of us not in high-risk specialties did not want to 
work in a hostile environment, where the smallest per- 
ceived mistake could lead to a damaging lawsuit that could 
jeopardize our careers. We did not want to view our patients 
as potential adversaries. We wanted to focus on the prac 
tice of medicine and the delivery of quality care. 

We had heard that the only way MICRA passed in 
California was through an organized strike by the majority 
of its physicians. They did not return to work until effective 
reform was brought about by their state legislature. We 
knew a bold political statement was needed in Nevada. 

Traumatic Events 

In the spring of 2002, orthopedic surgeons at the University 
Medical Center (UMC) Trauma Center in Las Vegas evalu- 
ated their risk and resigned, one by one, over a three-month 
period, citing excessive liability exposure. The lack of 
specialty coverage forced the center to close on July 3, 2002. 
The closure presented a particularly acute problem because 
the center normally serves a city of 1.5 million and the next 
nearest trauma center is 80 minutes away by helicopter. 
This action brought the insurance issue to the political fore- 
front and compelled Nevada's governor to call a special 
session of the legislature to address the crisis. 

I take regular call at the UMC Trauma Center to handle 
facial trauma cases. I also take call at many of the outside pri- 
vate hospitals where trauma patients were brought following 
the closure of the center. Those hospitals had no emergency 
in-house anesthesia coverage, and private practice general 
surgeons found themselves in charge of trauma patients. In 
some cases they had not taken care of such patients since 
their residencies, decades earlier. A number of people who 
were transported to area emergency rooms died shortly after 
arrival or had to be life -flighted to the closest trauma centers 
in neighboring Arizona or California. We will never know if 

those patients could have been saved or would have had bet- 
ter outcomes if our trauma center had remained open. 

With the special session scheduled, the governor assured 
the orthopedic surgeons that meaningful reform would be 
enacted, and they agreed to return to work. The trauma cen- 
ter re -opened ten days after it had closed. I joined a small 
number of doctors to attend the special legislative session in 
our state capital, Carson City, 400 miles north of Las Vegas. 
We left our practices to battle the trial lawyers' lobby. But 
we were clearly neophytes in the political arena, while the 
lawyers were playing on their home turf. We were not as 
effective in bargaining and, in the end, agreed to possibly 
ineffective legislation. 

Too Little, Too Late 

The new legislation, dubbed Assembly Bill 1 (AB1), created 
a $350,000 cap on non-economic damages from each defen- 
dant to each plaintiff, with two exceptions: gross malprac- 
tice and "special circumstances." Now, when have you ever 
heard a lawyer describing malpractice as mild? Of course, 
attorneys will characterize every case as one of gross mal- 
practice and special circumstances. 

We also agreed to dissolve the Medical Dental Screening 
Panel (MDSP), which had been created in 1986 as a 
response to our last malpractice crisis. This panel had been 
responsible for screening all malpractice cases before they 
could move to trial. The panel had not prevented any cases 
from going forward, even if there had been no determina- 
tion of malpractice, though it had made the process more 
difficult and costly for both sides. The process had also 
served as discovery for the plaintiff's side because the whole 
case needed to be laid out before the panel prior to trial. 

I believe that if the orthopedic surgeons had waited 
until a true MICRA passed before returning to work, they 
could have brought about substantive reforms. But under 
standably, the pressures on them were too great, and they 
could not live with the thought of patients dying because 
of their walk- out. 

In the end we did not get all we wanted, but it was a start. 
Like any type of tort reform, AB1 must go through the courts 
to test whether it can stand up to judicial review and con- 
stitutional challenge. Unfortunately, the $350,000 cap will 
apply only to occurrences after October 2002, further delay- 
ing the potential benefits. 

The situation has not improved much since the passage 
of AB1. Insurance companies are still asking the insurance 
commissioner for double -digit premium increases. Seven 



Insurance Policy for the Future 

other insurers have abandoned Nevada. Only five medical 
malpractice insurance companies remain in Clark County 
and only two of those are writing policies for surgeons 
and doctors in other high risk specialties. Physicians 
continue to restrict their practices as a form of risk man 
agement, and some are choosing to retire early or to leave 
the state altogether because of high premiums. 

Another disturbing trend in Nevada — especially Clark 
County — is the decreasing number of active physicians 
per 100,000 residents. Of the 50 states, we currently rank 
47 on that measurement. With the decrease in new physi 
cians and Nevada's continued population growth, we are 
on track to be number 50 soon. 

The biggest surprise after the passage of AB1 was the sharp 
rise in the number of malpractice case filings per month. This 
increase occurred immediately after AB1 took effect and is 
thought to have resulted from the abolishment of the screen 
ing panel. The average number of case filings per month 
tripled in 2003. This year we arc averaging approximately 74 
per month, a rate still significantly above what it had been 
before passage of AB1, but one that appears to be leveling out. 

Obviously the legislation itself did nothing to discourage 
attorneys from filing cases. In a reaction to this, KODIN, or 
Keep Our Doctors in Nevada, was organized to call for 
stricter MICRA style legislation and to take the issue 
directly to the people in the form of a referendum on our 
November 2004 ballot. If it passes, the initiative it describes 
will both remove the two exceptions that were created 
when AB1 passed and impose a limit on attorneys' fees. 
Unfortunately, a poll conducted in Las Vegas in March 
showed that, at that time, only 34 percent would vote yes, 
41 percent would vote no, and 25 percent were undecided. 

If we want to continue with our current private health care 
system, we need to make medical malpractice cases less 
lucrative for attorneys. As long as attorneys think they can 
navigate the court system easily and often emerge with a 
settlement — and possibly a jackpot award — they will con- 
tinue to pursue these cases. Tort reform with caps on non- 
economic damages will make these cases less appealing. 
Limitations on attorneys' fees will also make these cases 
less lucrative and will be helpful to patients. 

In line with tort reform, we also need jury reform to allow 
physicians to have a better shot at a well informed jury. The 
proposed federal tort reform now before the U.S. Senate 
would move medical malpractice cases to the federal court 
system. In Nevada, these cases are currently heard in district 
court, where the jury pool is based on the list of drivers 
licensed with the Department of Motor Vehicles. 

The jury pool for federal courts, by contrast, is drawn 
from registered voters, usually a more educated group. In 
addition, federal judges are appointed and therefore ha\ e a 
chance to act independently, instead of appeasing those who 
contribute the most to their re-elections. One positive move 
in this direction is that judges who sit for malpractice cases 
in Nevada are now required to have completed additional 
education, and almost all exemptions from jury duty were 
removed by the last legislative session 

Of course, the solution to the crisis would not be com 
plete ll we did not look to ourselves for improvements. As 
physicians, we always need to seek ways to decrease medical 
errors and to use evidence-based medicine in our decisions. 
We also need to protect peer review and to keep the results 
confidential to allow us to learn from our mistakes. We need 
to continue to educate doctors and medical students on 
the importance of both obtaining informed consent and 
warning patients about possible complications so they are 
not so surprised when things do not go as planned. 

I chair the Quality Care Committee at Nevada's largest 
hospital, which happens to be private. These are the kinds of 
changes we are always trying to make to protect both doc- 
tors and patients. We need to continue to work on commu 
nication with our patients when things do go wrong. Stud 
ies have shown that a simple apology is sometimes all a 
patient needs to hear. 

And finally especially in relatively sparsely populated 
states like Nevada, we need to continue to scrutinize any 
requests for insurance rate changes and to find incentives for 
insurance companies to offer malpractice coverage. 

With some of these changes, perhaps we can convince 
the doctors who work in Nevada to stay in Nevada. ■ 

Kathainc A. Keeky '94, DDS, is a private practice oral and maxillofacial 
surgeon and chief of the Division of Oral and Maxillofacial Surgcrx in the 
Department of Surgery at Sunrise Hospital and Medical Center in Las 
Vegas, Nevada, where she also chairs the Quality Care Committee. 



During the past year, Harvard Medical School has witnessed both changes 
and collaborative accomplishments, by JOSEPH B. MARTIN 





undergone extraordinary change in 
the past five years. We currently con- 
figure ourselves around the South 
Quad, which is now a hundred years 
in its development, and the North 
Quad, which includes Vanderbilt 
Hall, the Harvard Institutes of Medicine, and the New 
Research Building (NRB). ■ The NRB, which is connect- 
ed to the Harvard Institutes of Medicine, features about 
430,000 square feet for state-of-the-art research and is 
designed to encourage collaboration through co-location. 
Now that we have relocated from the Quad to the new 
building two of our basic science departments — the 
Departments of Pathology and Genetics — we can allow for 

new staff and juxtapose the members of both departments 
with scientists working at Reth Israel Deaconess Medical 
Center, Brigham and Women's Hospital, and the Dana 
Farber Cancer Institute. The new building centers primarily 
around themes of cancer research, genetics, vascular biology, 
and neuroscience. 

The freeing up of space on the South Quad by this reloca- 
tion has allowed us to focus on where science is headed in 
this century. Working with our department chairs, we have 
formulated five areas of emphasis, many of which are inter 
disciplinary and interdepartmental. 

The first area of emphasis is the new Department of Sys- 
tems Biology. In creating this department, we had recog 
nized the existing strengths of systems neuroscience and 
wanted to build further on them. Chemical biology, includ 
ing chemical genetics, uses modern chemistry to dissect 
gene functions and to look at interruptions of genes. We 
received a grant of approximately $50 million from the 
National Institutes of Health to support research led by 
Dennis Kasper, former dean for academic programs at HMS 

and now director of the Channing Laborato 
ry. With that grant we have formed a major, 
collaborative research effort in emerging 
infections and vaccines in areas relevant to 
national biosecurity concerns. And finally, 
by establishing a new Center for Molecular 
and Cellular Dynamics, we have enhanced 
the area of structural biology. 

The Department of Systems Biology is the 
first of its kind in the nation and the first 
new department that we've formed at HMS 
since Philip Leder '60 joined the School to 
lead the genetics department in 1980. We 
anticipate more than 20 faculty recruitments, 
and it is my hope that Walter Cannon, 
Class ot 1900, would be pleased to know 
that we have restored physiology to a 
department structure — the modern physi 
ology of the twenty-first century. 

Second, we created the Broad Institute. 
This remarkable feat was accomplished by 
MIT President Charles Vest and Harvard 
President Lawrence Summers working with 
the Broad family of Los Angeles, who approached us because 
of a family interest in inflammatory bowel disease and their 
connection to physicians at Massachusetts General Hospi- 
tal. Interested in the potential of finding genetic solutions to 
ulcerative colitis, they met with Eric Lander, who has been 
responsible for perhaps 25 percent of the human genome 
decoding process. When they tried to recruit Lander to Los 
Angeles, he expressed his preference to stay in Boston, so 
they came to us with a donation of $100 million pledged over 
ten years, with additional private funds to be raised, to 
establish the institute in Boston. Lander, as the first director 
of the Broad Institute, now has a joint appointment as pro- 
fessor of systems biology at HMS as well as a professorship 
at MIT and membership in the Whitehead Institute. 

The third area of emphasis was the creation of the Har- 
vard Stem Cell Institute this past spring in response to the 
scientific need to explore the therapeutic implications of 
stem cell research — and to do so sooner rather than later, 
in light of the federal policy on stem cell research that lim- 
its access to a few cell lines. Douglas Melton, a well-known 




researcher at the Harvard Faculty of Arts and Sciences and 
a Howard Hughes Medical Institute investigator, has 
joined with David Scadden, a professor of medicine at 
Massachusetts General Hospital, and approximately 50 
other faculty from our major hospitals, the Medical School, 
MIT, and the Faculty of Arts and Sciences to form the Har- 
vard Stem Cell Institute. Melton, the father of two chil- 
dren with juvenile diabetes, has been instrumental on the 
national scene in calling into question the federal restric- 
tions on stem cell research. 

Stem cell research uses multi- or totipotential cells, 
which, unfortunately, gives rise to ethical concerns. Dealing 
with these issues is part of our plan; the questions surround- 
ing whether it is legitimate to take frozen embryos that 
would otherwise be discarded and use them for therapeutic 
purpose are central to the concerns our country now faces. 

Using the blastocytes, a collection of perhaps 60 or 70 
cells, a scientist can, by removing the inner cell mass, obtain 
stem cells that can be kept in culture in perpetuity and 
become a line that then allows the scientist to collect, at 
various stages, multiples of that original stem cell family. 
The stem cell is unique in that it is capable of self- renewal, 
which means that a single stem cell can give rise to a daugh- 
ter stem cell, which can then give rise to a further stem cell. 
This process is a normal part of human physical develop- 
ment, but it is also called into action by physiologic stimuli 
prompting tissue regeneration. 

The plan for the Harvard Stem Cell Institute is framed, 
in part, around the following considerations: that the pro- 
portion of the population over age 65 will double by mid- 
century; that the most costly care is provided not to the 
acutely ill but to those with chronic organ failure; that 
disability drives up health costs and drives down produc- 
tivity; and that tens of millions of people now suffer 
from such illnesses as Parkinson's disease, diabetes, and 
Alzheimer's disease. 

The goal of the institute, which will be seeking private 
funding to carry out its activities, is to transform the basic 
science of understanding stem cell proliferation and to mod- 
ify those cells in order to place them into the appropriate 
environments for treatment. 

The near-term targets of potential stem cell use are; blood 
diseases, in which stem cells are critical to the treatment of 
cancer, aplastic anemia, and bone marrow disorders; cardio- 
vascular disease, in which the promise is already evident in 
clinical trials using stem cells inserted into atheromatous 
areas of an artery; diabetes, in which stem cells clearly can be 
seen as the energy, insulin -producing moiety that offers hope 

of taking patients off insulin, perhaps within my lifetime; 
and neurodegenerative diseases such as Parkinson's disease. 

Our fourth area of emphasis is an expansion of life sciences 
in the AUston- Brighton area, where Harvard has acquired 
substantial amounts of real estate over the past decade. 
This property — adjacent to Harvard Business School and 
Harvard's athletic facilities — will be the site, totaling more 
than 200 acres, of significant development over the coming 
years, with the first construction scheduled to begin around 
2006. The plans for this initiative have been the result, over 
the past year, of vigorous activity involving many faculty, 
staff, and students across the entire university. Those of us 
in science have been gratified by President Summers's 
clear assertion that life sciences should be a substantial 
component of the activities that take place at that venue. 

And, fifth, our central mission: a transformation of medical 
education, almost exactly 20 years after the New Pathway 
planning was begun under former Dean Daniel Tosteson '48. 
In transforming medical education, we face several great chal 
lenges, the first of which centers on the content of the curricu 
lum. What should we teach? What is the core material? 
What should every student know — or know how to research? 

Another challenge is the contemporary crisis in medical 
education costs, specifically the issue of student debt. How- 
can we give our students both the education they need and 
a future that isn't compromised by student debt? 





,'*' '"V'- 



RETURNING TO THE ROOST: Alumni reported enjoying the dean's 
update on the School, as well as the other speakers' perspectives 
on the nation's health care financing crisis. 

The third challenge lies in the areas of promoting 
professional development and teaching our students com- 
passionate and culturally competent care. 

A fourth challenge is the compensation of clinical teach 
ers. Probably no single issue has our faculty more exercised 
and worried, and yet more eager to work on solutions than 
the question of how to compensate them for their teaching. 

Finally, all of these issues are further complicated by 
the cultural clinical chaos of our academic health centers: 
the short term stay, the acuity of the patients who come 
in, the rapidity with which they are discharged, and the 
inability to find an hour when a student, a faculty member, 
and a patient can talk and learn from each other. 

These are some of the major issues we've been tackling 
recently. And as we think about the future, a number of 
priorities emerge: 

Establishing new objectives and standards for our graduates. 
How do we define the quality of the medical education we 
are delivering? How do we measure it? How do we prepare 
our graduates to become everything they want and should 
be in the medical profession? 

Offering new initiatives in clinical research to our first year students 
when they arrive. Clinical research will increasingly be the 
academic and clinical trajectory of our students. 

Training physician scientists. Harvard currently trains more 
physician scientists than any other school in the country. 
We now have a national crisis in the scarcity of the supply of 
physician-scientists, though, and we need to train them even 
more efficiently and effectively to participate in a broad 
range of opportunities that stem all the way from evidence- 
based medicine, health care reform, and medical error pre- 
vention and extend to fundamental genetics, biochemistry, 
systems biology, and molecular biology. 

Harmonizing basic scientists' and clinical scientists teaching and 
scholarship. We now have approximately 800 medical stu- 

dents and 600 doctoral students — and 
they barely cross paths. We need to bring 
them together in clinics and courses to 
learn from each other so that the clinicians 
know more about science and the scien- 
tists know more about clinical medicine. 

Making the medical school curriculum seam- 
less from the first through the final year. Most 
U.S. medical schools teach a two-by-two 
curriculum: two years of science, two 
years of clinical work. We've put a little 
clinical work into the first year and a bit 
more into the second year. We've tried to 
put a little science into the fourth year and are still consid- 
ering further improvements. 

Creating a continuum of medical education. It is critical to link 
the MD program with the residency program and with the 
continuing medical education postgraduate experience. 
This is the toughest issue in medical education today — 
how to develop that entire continuum from which our 
practicing faculty can benefit. 

Placing an emphasis on longitudinal experience. We want our 
students not just to see patients at the bedside before the 
procedure, but also to have a chance to follow patients and 
their families throughout the entire experience of illness and 
wellness, to talk about prevention and epidemiology. 

Teaching teachers. We have formed the Academy at Harvard 
Medical School, which now has a membership of 212 teach- 
ers who are eager to help improve teaching throughout the 
Medical School environment. 

Establishing new guidelines for rewarding our teaching faculty 
through promotion and devising fair and appropriate faculty com- 
pensation. In this context, compensation is not only 
money — it's also reputation, promotion, and recognition 
in the profession as a teacher. We are excited about the 
Academy, whose members range from students to senior 
professors. More than 50 innovative projects have already 
been funded, including the Academy Fellowships in Med 
ical Education, named after notable past and present fac- 
ulty members Curtis Prout '41, Herbert Morgan '42, and 
the late Hans Zinsser '42. These fellowships allow our 
junior faculty to take time to think deeply about how to 
pursue excellence in teaching. 

I conclude with words by Ralph Waldo Emerson: "Do 
not go where the path may lead. Go instead where there is 
no path and leave a trail." ■ 

Joseph B. Martin, MD, PhD, is the dean of Harvard Medical School. 


Reunion Reports 

Reunion Report 



eunion Reports 

Reunion Reports 


1944 Harold F. Rheinlander 

A good time was had by all who 
attended our reunion. More than 
half of the original members of the 
Class of 1944 have survived these 60 
years since graduation. There was 
general agreement among those 
present that we have withstood the 
ravages of time remarkably well. 

The class dinner, held in the 
Faculty Room of Gordon Hall, for- 
merly known as Building A, was 
attended by 47 and the luncheon 
at the Harvard Club by 42 plus 
5 of our dental school classmates. 
Anecdotes, fueled by vivid memo- 
ries of some of our more note-wor- 
thy experiences at HMS, passed 
around the room at both events. 

Class members expressed con- 
siderable interest in organizing 
another reunion in two years even 
though HMS does not officially 
sponsor reunions beyond the 60th. 
Should we elect to have another 
class meeting during Alumni 
Week, the alumni office staff have 
assured me they will help with 
arrangements. I will contact class 
members later in the year to assess 
the level of interest and to elicit 
suggestions about activities that 
might appeal to the group. ■ 



Reunion Report: 

Reunion Report: 




1949 e Francis J. Riley 

Ten of us, our wives, and one lovely 
widow attended the Thursday evening 
reeeption and dinner at Countway 
Library with pleasure and a certain 
solemnity. That morning and afternoon, 
some of us were fortunate enough to 
hear the Class of 1979's symposium, 
which was fascinating and encouraging. 
Others attended the HMS faculty sym- 
posium, which was also impressive. 

Friday was Alumni Day on the Quad 
rangle, with the business meeting and 
presentations of reunion gifts. Dan 
Federman '53 beautifully moderated 
"Navigating the Health Care Crisis." He 
even diplomatically managed a loqua- 
cious audience-participant with a 
Mark Twain rejoinder: "You may be 
right." Dean Joseph Martin gave one of 
his usual forward-looking presenta- 
tions. Lunch on the Quad and our 
reunion class photo of just six class- 
mates and their wives followed. Finally, 

thirteen happily adjourned to the Stage 
Neck Inn in York Harbor. Maine, for 
the weekend. 

We were the first post-World War II 
class, entering in 1945 and graduating 
142 MDs, including the famous first 12 
women, and 10 DMDs in 1949. Fifty- 
five years later, 87 MDs are still stand- 
ing (61 percent) and 4 DMDs (40 per- 
cent), at 80- plus years. Time obviously 
has taken its toll, both in lives and 
states of health. There is every medical 
reason to expect, however, that when 
the Class of 1974 celebrates its 55th 
reunion in 25 years, they can anticipate 
prevailing to age 90 and beyond. 

I should mention that as the little- 
known tax collector for the class reunion, 
I eventually replaced the uncommonly 
nice chairman, Morgan Yigneron, who 
was ailing seriously. Significantly, the 
reunion committee held only a single 
meeting, in the fall, which might have 
affected attendance. ■ 



eunion Reports 

Reunion Reports 



1954 ■ Thomas O'Brien 

A record breaking 68 members of the 
Class of 1954 plus spouses and a few 
children attended one, and most attend- 
ed all, of our reunion events. A reception 
and dinner were held on Thursday 
evening in the domed hall of the 
School's huge, glass New Research 
Building, fittingly adjacent to our nos- 
talgia drenched Vanderbilt Hall. 

After the program and lunch in tents 
on the HMS lawn on Friday, a charter 
bus took classmates to the Chatham 
Bars Inn on Cape Cod and returned us 
to Logan Airport and other sites on 
Sunday. Clear, sunny days and vast 
beaches, dunes, gardens, and verandas 
encouraged walking and schmoozing. 
Microphones at the Thursday and Fri- 
day dinners and the Saturday clambake 
prompted almost everyone to talk to 
the assembled about what they remem 
bered, liked, disliked, did then, have 
done since, and still want to do. 

At the core of the reunion were the 
casual, meandering conversations on 

the bus, at meals, in ocean-viewing 
wicker chairs, or on walks. Many 
reflected on why they so enjoyed talk 
ing with classmates they had not 
known well in medical school. We were 
all shaped by the times we grew up in, 
now foreign to all those younger people. 
We were surprised to have been admit- 
ted to HMS, frequently overwhelmed 
by the strange, often hilarious activities 
of medical school and later training, and 
grateful to our accomplished, colorful, 
and supportive HMS faculty. 

Our careers have been complex, var- 
ied, and buffeted by chance and entan- 
gling health care systems. But they are 
better understood by one another of us 
than by others. And we now share 
increasingly the stages-of-life stuff; wc 
are still puzzled by our children and are 
fawning over our grandchildren. We 
enjoy much that is in our memories and 
more that can be drawn from the collec 
tive memory of the Class of 1954, so 
much so that many wish to gather again 
before another five years pass. ■ 



Reunion Report: 

eunion Report 




1 959 ■ Bucknam McPeek 

Forty one members of HMS and HSDM 
attended our reunion; including guests, 
74 celebrated the great event. We start- 
ed Wednesday evening with a cocktail 
buffet at the MIT Faculty Club. The 
room offered a view over the Charles 
River basin and a splendid vista of 
Beacon Hill and Back Bay. Classmates 
and families renewed old acquaintance 
and brought each other up to date. Once 
again we demonstrated that '59ers real- 
ly enjoy each other's company. 

The following evening we gathered at 
the Union Club of Boston for the class 
banquet. At the end of dinner, classmate 
Bob Blacklow spoke about HMS then 
and now, and what the future might 
bring. From School archives he unearthed 
our class statistics and compared them 
with those of current students. The good 
news is that we as a group would still do 
well in today's admissions competition. 

Friday afternoon the Class of '59 fled 
north to the Black Point Inn, just south 
of Portland, Maine. This storied New 
England resort was our headquarters for 

the next 48 hours. The food, drink, and 
recreation were super, but the myriad 
opportunities for both lively and quiet 
conversation were the best feature. The 
class held two informal meetings. Satur 
day morning's loosely centered on retire- 
ment. After some general discussion, 
classmates focused on opportunities for 
improving the lot of our fellow man. It 
almost seemed as if those who had retired 
and those who were considering it were 
so imbued with the Puritan work ethic 
that they couldn't bear the guilt of not 
doing good deeds. This lively conversa- 
tion lasted for more than two hours. 

On Sunday morning, we talked over 
projects that we might undertake to ben- 
efit medical care generally. We then dis- 
cussed plans for our 50th reunion and 
strategies for enticing more of our class- 
mates to celebrate, both by coming and by 
contributing to the reunion book. We 
are getting older, and after the 50th, the 
number of active classmates will begin to 
decrease. We'll have later reunions, but 
the 50th will probably be the last great 
opportunity to get us all together. ■ 


eunion Reports 

Reunion Reports 




1 964 Robert McCarley 

Our reunion, blessed by June-perfect 
New England weather and the presence 
of some 90 class members and guests, 
began Thursday evening with a reception 
at the South End home of Dave Chapin. 
While catching up on each other's lives 
we enjoyed this classic renovated Boston 
row house, circulating and conversing up 
and down its three levels. At the class pic- 
ture the next day, we were surprised and 
pleased to see Professor George Erikson — 
who had tricked us in a 1960 anatomy 
quiz by asking where the Circle of Tugo 
was — also taking a picture of us! 

Friday night was dinner at the Har- 
vard Faculty Club, where we enjoyed the 
Theatre Room as a backdrop to the latest 
events in our lives and, appropriately, to 
a screen show of our photos and the 1999 
reunion. Jean Hurd, wife of Class Trea- 
surer Joe Hurd, was accorded a standing 
ovation for her good work as the HMS 
alumni coordinator. On Saturday we 
journeyed to the home and bucolic farm 
of Joe Dorsey, where we communed with 
each other and with the goats and sheep 
and enjoyed an old-fashioned clambake. 

There may be something magical about 
ha\ing reached the age of 65, for the atmos- 
phere was one of warmth and openness, 
even more than at the 35th, so much so 
that Steve Jackson talked about the after 

glow that would follow the reunion. Some 
of us are still in love in with our careers and 
some regard our relationship with medi 
cine as a dying one, but we all felt open to 
talk about our lives, our class, our joint 
initiation into the mysteries of medicine 
and HMS, and our shared life's journey. 

Since we have done pretty much what 
we could be expected to do in terms of 
careers, we are now thinking about the 
expression of other facets of our lives. 
The new interests include the visual arts, 
music, travel, and adventure. Retirement 
begins to be more on our minds. About 
a third of us are already there, and still 
more are cutting back on time at work 
in favor of these other interests. 

All sweetness and light and no notes of 
discord or dissatisfaction? The managed 
and independent care pathway wars 
seemed to have receded into the distance, 
in marked contrast to our 25th. But, as we 
reach the time when the fate of our estates 
is more acutely brought to mind, the con- 
troversy over whether the Harvard endow- 
ment fund managers are demonic, greed 
mad beings intent on becoming masters ol 
the universe, or simply professionals doing 
a super job of enhancing Harvard's wealth 
to all our benefit and getting rewarded 
commensurately, seemed to resonate. 

We had renewed contact and updates, 
with pleasant surprise over good for- 
tune — and deep sympathy for tragedy, 
most often in the form of personal illness 
of class members or their family mem 
bers, events that appeared to be genetic 
roulette — unfair, unearned, unmerited — 
and events to which we are all now 
increasingly vulnerable. 

The large number of our offspring who 
are now entering medicine suggests that 
our core idealism and love of the profes 
sion has been transmitted. The new- 
generation might not be as uncomfort 
able as we in a different environment, 
and, indeed, might prefer it. 

We thought of and missed those not 
there and wished still more could have 
come. But we were grateful for being in 
touch through Marv Corlette and Kay 
Aldrich's compilation of the reunion book. 
Joe Hurd has since posted many reunion 
photos on; email him at for more details. 

Let's keep in touch, and see you at 
the 45th 1 ■ 



eunion Report 

eunion Report: 




1 969 ■ George E. Thibault 

Twenty two members of the Class of 
1969 and 16 spouses attended all or part 
of the reunion activities. Mike and 
Gretchen Harrison traveled the farthest 
(from San Francisco). Thirteen of the 22 
arrived from out of town, including 
Curt Freed, who arrived after most of us 
left the clambake on Saturday. He gets 
an A for effort. 

Thursday evening we enjoyed a recep- 
tion at the School's New Research Build- 
ing on Avenue Louis Pasteur, and we 
were impressed with this latest addition 
to the campus. Friday night we had din- 
ner at the newly renovated Downtown 

Harvard Club, where we marveled at the 
extraordinary views of Boston. 

On Saturday the Kanners hosted a 
delicious clambake on their exquisitely 
landscaped property in Lincoln. It was a 
mellow time, with much talk about 
family and health rather than work and 
retirement. We took both comfort and 
joy in rekindling relationships and shar- 
ing our personal lives. We were remind- 
ed how privileged we were to spend 
those special years with such a great 
group of people. Our only regret was that 
we did not see more classmates, but we 
know there will be a larger turnout for 
our 40th. ■ 



Reunion Reports 

Reunion Reports 



1974 Carolyn Compton 

Well, they had to kick us out of Count 
way I ibrary on Friday night. I think we 
could have gone on "reun-ing" for quite 
some time after they cleared away the 
dessert dishes. 

We were about 60 people at Friday's 
dinner, a small but respectable number 
given that the event overlapped with 
the Harvard Radcliffe reunion of the 
Class of 1969 in Cambridge. We ate and 
talked, drank and talked, and hugged 
and talked — and were still talking on 
the way down in the elevator and out 
onto the street. We are nothing if not a 
loquacious group, but it was much more 
than just conversation. It was connec- 
tion and reconnection. We were all dif- 
ferent from our former student selves 
and yet still the same. 

For many, children are now finishing 
high school or college or starting graduate 
school. Others of us have started over in 

our private lives, our professional lives, or 
both. Whether we have changed or great 
ly modified our original careers (Gloria 
Singleton- Gaston is starting a second 
career as a singer, between patients!), have 
already retired, or continue to toil in the 
fields of academic medicine, we expressed 
gratitude for the opportunity to serve. We 
also felt the generation gap with today's 
medical students and residents who see 
their lives in medicine within limits. 

We agreed that Margaret Ross deserved 
the prize for the longest essay in the 
reunion book and that Tim Russell was 
still our tallest classmate. We also uni 
versally missed Dave Calkins at the 
reunion and send our love. 

The clambake was relaxed and fun. 
Saturday was sunny and breezy (paper 
plates flying everywhere), and we ate, 
drank, and talked, talked, talked. We 
had a glorious time even though it was 
hard to talk with lobster bibs flapping 
over our faces. Dave Koh is a saint to 
open his house to us for this event every 
time we have a reunion! 

As has become a time-honored class 
tradition, we spent the late afternoon 
jamming with the Kohs' Porch Rock 
Band, now more appropriately named 
the New Aging Rock Band or the 
Boomers Against Geezerhood Rock 
Band. Just remember, kids, Mick Jagger 
will always be older than we are! Dave 
even had a songbook of lyrics prepared 
for the event — not that any of us could 
understand a single word of "La Bamba" 
(what does "arriba y arriba" mean any- 
way?). We were frankly terrible but had 
a great time being just that. I can imagine 
the caustic feedback that Dave must still 
be getting from his neighbors. Despite 
that, I am sure he is proud that the Class 
of 1974 still rocks. 

Mitch Max and I want to thank the 
members of the Reunion Committee and 
all our classmates who came and made 
this reunion so lovely. Thirty years is a 
long time, and I still have trouble getting 
my head around the realization that 
so much time has passed. The upside 
of passing time is the increasing value 
of shared memories and aspirations and 
old friends. We celebrate that. ■ 



Reunion Reports 

Reunion Reports 




1 979 ■ Anne St. Goar 

It was hard for us to believe that 25 years 
had passed, but once the shock receded 
we had a fabulous reunion. People repeat- 
edly mentioned how relaxed we all 
seemed and what fun it was to connect 
with old friends and to make new ones. 

For Thursday's class symposium we 
decided not to hold talks on updates of 
various diseases that we could hear at 
medical conferences. Instead we asked 
people to share life experiences and 
their often unique paths in medicine. 
Dan Rome and Deborah Prothrow-Stith 
did a superb job organizing a diverse 
and stimulating group of classmates. 

Samplings from the symposium 
included Richard Rockefeller's descrip- 
tion of being a patient with chronic 
myelogenous leukemia and the power of 
the Internet; Ken Robinson's politicking 
and preaching as Tennessee's commis- 
sioner of health; Deborah Prothrow- 
Stith's discussion of the overlap — or 
lack thereof — of medicine and public 
health and her introduction of Nancy 
Oriol — now associate dean for student 
affairs at HMS — because of her fabu- 
lous community outreach work with 

the Family Van; Bill Bayer's inner city 
family and community medicine; Barry 
Tortella's performing surgery interna- 
tionally in needy areas; Jill Stein's 
combining of medicine and politics by 
running for governor of Massachusetts 
on the Green Party ticket; and Marlene 
Krauss's (unsurprising) merging of 
business and medicine by financing 
medical start-up companies. These 
talks generated discussions that contin- 
ued into the evening's dinner. 

On Friday we joined the Alumni Asso- 
ciation meeting and luncheon and then 
split off for dinner at Pine Manor 
College, ably organized by Susan Haas 
and Dea Angiolillo. The highlight of the 
dinner was a spellbinding performance 
of bell}' dancing by \ larguerite Barnett — 
complete with real swords. (We're still 
wondering how she got those past air- 
port security. ) 

We were blessed with a perfect day 
for Saturday's informal outdoor lunch 
at Mary Briggs's lovely home in Lin- 
coln. We left wishing we did not have 
to wait five years until the next reunion 
but also knowing that those years will 
pass quickly. ■ 



leunion Reports 

Reunion Reports 



1984 ■ Lisa lezzoni 

Twenty-five members of the Class of 1984, 
as well as spouses, partners, and many 
children, gathered for a picnic under a 
perfect blue sky and towering trees at 
the \\ ellesley home of Sally McNagny, her 
husband. Bob Green, and their three crril 
dren. Sally's house sits upon a small hill, 
and from my vantage I could see most 
people arriving. They looked tentatively 
upward as they climbed, seeming unsure 
what to expect. But anxieties vanished 
as people warmly greeted each other. The 
afternoon was lovely and passed too 
quickly, as have the past 20 years. 

Two topics dominated talk: careers 
and personal lives. Yes, we all now speak 
with experience and some authority; we 
are definitely mid-career. Our careers are 
diverse. Some spend most of their time in 
practice. Others have left practice entire- 
ly, hold significant administrative posi 
tions, lead training programs, conduct 
research full time, travel the globe 
for science, or manage concatenated 
careers — linking practice, research, 
administration, and teaching, in varied 
combinations. Some classmates face 
transitions, relocations, or major shifts 

in occupations. Nonetheless, everyone 
seems up to the challenges they confront 
at work — even if, as in some instances, 
their careers are not exactly what they 
had anticipated. 

On the family front, of course, some 
people are married with children, and 
some are not. Many with progeny 
brought their offspring, who ranged 
in age from toddlerhood to later teens. 
What struck me most forcibly was the 
amazing power of genetics — some chil- 
dren are spitting images of their parents. 
And since certain children are nearing 
ages at which we first knew their par- 
ents, these visions are spooky indeed! 
The next generation, though, seems as 
energetic, creative, and focused as their 
parents — a reassuring thought. 

Rick Mitchell, who with his wife, 
Diane, was among the first to arrive at the 
reunion, will have the tinal words: "I'm 
still excited about what I do, even more 
impressed with what my classmates have 
accomplished, and very glad I chose med- 
icine for a career. It was terrific to see so 
many of the group. Now I'm redly excit- 
ed about the 25th reunion in 2009. where 
we'll get almost everybody back!" ■ 



Reunion Reports 

eunion Report 

1989 Dominic Zambuto 

The Class of 1989's 15th reunion marked 
yet another milestone for us and a time 
to reflect on how we have changed in the 
past five years. Although attendance was 
low (perhaps an indication of how busy 
we have become), those who came 

enjoyed renewing old friendships and 
catching up with classmates we had not 
seen in years. Friday night we had a 
reception in the New Research Building 
at HMS. This facility is on Avenue 
Louis Pasteur and surrounds the for- 
mer Boston English High School, now 
a research building. The HMS campus 
has growTi so much since we were there. 

Saturday was the perfect day for a 
picnic at Bob and Kathy Giugliano's in 
Westwood, where the children outnum- 
bered the adults. All who attended had a 
great time. I cannot thank Bob and Kathy 
enough for being such great hosts. San- 
dra and Matthew Meyerson have already 
volunteered to host the 20th reunion 
picnic at their home in Concord. 

Five years will pass quickly. Please 
plan to attend the next reunion. ■ 





1994 Marc S. Sabatine 

Our reunion proved a wonderful oppor- 
tunity to see old friends. On Friday 
night, we gathered on the terrace at 
Davio's, greeting each other as we 
sipped wine and gazed at the Charles 
River on a beautiful summer night. We 
had an enthusiastic showing from all 
corners of the country. Thankfully, most 
of us have finished our extended train- 
ing and are settling into life as attend- 
ings. Liz Speliotes, however, wins the 
award for most persistent student. Hav- 
ing earned her MD and PhD and com- 
pleted her internal medicine residency 
at Massachusetts General Hospital, Liz 
is just now about to launch into a gas- 
trointestinal fellowship! 

We capped the evening off by watch- 
ing clips from a recently uncovered video 
that Ben Medoff shot backstage during 
our Second Year Show We got to see 
Aaron Caughey '95 and Heidi Behforouz 
giving acting tips, Tim Friel posing as 
Judah Folkman '57, Lauren Solanko 
Koniaris applying makeup to cover the 

rash she got from the makeup the night 
before, Amber Barnato wearing an arm 
cast, and Macrene Alexiades-Armenakas 
wearing a bullet bra. And, of course, we 
heard the incomparable Lauren Orloff 
Glickman singing "Everybody Walk 
Now!" and "It's in His Piss." 

The next day we met up at Larz 
Anderson Park. More than two dozen 
alarmingly energetic kids frolicked as 
we enjoyed delicious barbecue catered 
by the one and only Redbones. Terry 
Shanahan Czeisler, Tim Friel and Kristin 
Sinnock Friel, Karen Loeb Lifford, and 
Andy Pienkny, already proud parents at 
our last reunion, brought their veteran 
kids back for round two. Jessica Cohen 
Dudley, expecting during our fifth 
reunion, is now a mother of three, and 
many other classmates have happily 
joined the ranks of parenthood. 

It was an awesome weekend, and it 
was great to see everyone moving for- 
ward professionally and personally. 
Here's to us all gathering for our 15th 
reunion! ■ 



leunion Reports 

Reunion Reports 


1999 Jean Ou Ung 

It's hard to believe that five years have 
already passed since we last walked the 
halls of the Medical Education Center as 
a class and said farewell to HMS. As we 
returned for this first of many reunions, 
some as senior residents, some as fellows, 
some as new attendings, and some as 
medical consultants, we remembered 
what an integral part of our lives those 
four or five (or six, seven, or eight) years 
at HMS were in our development as 
physicians and as human beings. 

On June 11, a small and cozy group of 
us met at the Elephant Walk restaurant 
on Beacon Street for dinner and drinks. 
We reminisced over the good times at 
HMS and divulged new stories (and 
gossip) about other members of the 
Class of 1999. Everyone apparently 
enjoyed reading the reunion book. Mar 

riages, babies, new homes, new jobs, and 
promotions — they were all exciting to 
read about in the book. 

The next afternoon, after chasing down 
the Redbones delivery truck from across 
the highway, almost 30 of us (spouses, chil 
dren, and all) gathered for a barbecue 
lunch beside the Charles River. Yummy 
food, great weather, and even better com- 
pany made the afternoon one to remember. 

While our class as a whole has expand 
ed with the many new family members, 
both spouses and children, we have also 
transformed since medical school from 
students into doctors and teachers of 
medical students. The reunion was a 
time to catch up on the professional and 
personal growth of all our classmates 
and friends. I hope we will see many 
more of our classmates at the tenth 
reunion, if not sooner! ■ 







Elective Medicine 


LiLw they'll have a chance to east their ballots tor a fresh addi 
tion to the usual slate of Democrats and Republicans 
vying for state representative: Jill Stein 79, running on the ticket 
of the Green- Rainbow Party. It will not be Stein's first bid for 

elected office. When Green Party 
activists began searching for an articu 
late, passionate candidate to get their 
message out in the 2002 Massachusetts 
gubernatorial race, they tapped Stein 
even though, in terms of political experi- 
ence, she was far greener than party orga 
nizers might have preferred. "I wasn't a 
member of any political party, and I had 
never run for anything in my life — other 
than secretary of my high school student 
council," she cheerfully concedes. 

Although the choice of Stein, an 
internist and long-time public health 
activist, caught many outside the Green 
Party by surprise, Stein views her guber- 
natorial candidacy as the natural evolu- 
tion of the same convictions that had 
drawn her to medicine. For Stein, the 
personal has always been political, going 
back to her childhood in an affluent, all- 
white suburb of Chicago. 

"I grew up keenly aware of the impor- 
tance of socioeconomic status," says 
Stein, who viewed the civil rights move- 
ment partly through the lens of her 
family's African American housekeeper's 
perspective on the unfolding drama. 
She made an idealistic commitment to 
hands-on action as an undergraduate 
at Harvard, where her interest in social 
change led her to a combined major in 
psychology, sociology, and anthropology. 

But her overriding passion in that 
period of her life was music. A guitarist 
and singer. Stein spent the year after her 
college graduation as a troubador play- 
ing street music as part of Boston's "Sum 
merthing" public arts program. It would 
not be the last time that the purity of 
her vision bumped up against practical 
experience. "I quickly learned," she says, 

"how tough it is to survive as an artist 
without commercializing your music 
and to remain true to your values." 

Stein brought with her to HMS the 
strong interest she had always nurtured 
in public health. When, as a medical stu- 
dent, she heard guest lecturer H. Jack 
Geiger discuss the community health 
center he had founded in the Mississippi 

PERFECT HARMONY: Before medicine 
and politics, music was the realm in 
which Stein fused passion and idealism. 

Delta, she was riveted by his description 
of a place that functioned as a catalyst for 
social change as well as personal health. 
Although that lecture crystallized in her 
mind the nexus between medicine, edu 
cation, and community empowerment, 
Stein nonetheless found herself swept 
up in mastering what she describes as 
"the nuts and bolts of medicine." 

Stein plunged into a general internal 
medicine practice. But once her second 
child was born, she cut back on her 
career. It was this period of parenting 
rather than doctoring that intensified 
her commitment to issues of environ- 
mental health. She became intrigued by 
an emerging medical literature linking 
behavioral disabilities in children and 
early-life exposure to environmental 
toxins. Her watershed moment came 
during a sustainability conference dur- 
ing which she heard a speaker claim that 
human breast milk can be vulnerable 
to contaminants. When the speaker 
could not answer her request for spe- 
cific evidence, she decided to uncover 
the information herself. 

The data she found troubled her both 
professionally and personally. "As a doc- 
tor, I wondered why I hadn't heard any- 
thing about these issues," she says. "And 
as a mother who had nursed her children 
believing I was improving their health, I 
began to worry that I had unwittingly 
exposed them to serious risks." 

Eventually Stein was reassured that 
the benefits of breastfeeding far out- 
weigh any risks. Of much greater con- 
cern, she found, was the effect of pollu 
tants on the fetus, whose brain is at the 
most vulnerable stage of development. 
"Adverse impacts," she says, "on brain 
development and behavior — such as 
impaired attention, learning, and memo- 
ry — have been demonstrated at levels of 
general population exposure to a variety 
of toxic pollutants." 

Stein's new awareness led her to 
become involved with Physicians for 
Social Responsibility. She helped prepare 
a curriculum for physicians and nurses 
designed to train them to educate parents 
on avoiding exposure to toxic threats 
found in consumer products, food, and 
the environment. "That's important," she 
says, "because poisons such as mercury, 
lead, pesticides, dioxins, and PCBs aren't 
going away any time soon. And that's 
why we need solutions at the policy level. 



so we don't put out more persistent 
toxins and make the problem worse." 

This initial immersion in public health 
and policy issues was. Stein says, "a kind 
of boot camp" for her later entrance into 
politics. Her efforts led to, among other 
breakthroughs, regulations to clean up 
incinerator emissions, upgrades in federal 
and state fish advisories to protect 
women of reproductive age and children 
from mercury exposure, and the adoption 
of new standards to clean up Massachu 
setts coal plants. 

Yet the road to public health victory 
proved shocking to the political novice 
Stein was at that time. "I went to town 
boards and the legislature armed with 
rational, scientific evidence and grass- 
roots support for win-win solutions — 
proposals that improve health and the 
environment, save money, and create 
jobs," she says. "Yet I was dismayed to dis 
cover that none of it mattered." Stein was 
stunned when, as she describes it, "a 
hired gun for the incinerator industry 
was given free reign to talk while I — tes- 
tifying as a concerned mother and ph.) si 
cian — was allowed about 30 seconds." 
But she adds, "I never grew disillusioned; 
I just became more determined." 

By the time she entered the political 
fray in 2002, Stein had already spent years 
advocating with nonprofit advocacy 
groups such as Clean Water Action and 
Physicians for Social Responsibility. 
Even so, she says, "running for statewide 
office seemed intimidating. But finally 
the Greens persuaded me that I could just 
keep doing what I was already doing, 
advocating for health and environmental 
causes. But by calling it a campaign, they 
pointed out, I could bring these issues to 
a broader audience. That was irresistible." 

Stein's campaign ended with the elec- 
tion of Republican Mitt Romney as Mass 
achusetts governor, but not before she had 
made a powerful impression with her 
articulate performance in the one televised 
debate in which she was allowed equal 
time. "I was ignored as usual by the other 

' The other candidates droned on with their all-too-familiar 
sound bites, while I tried to propose real solutions, in 
the tradition of good medical problem-solving." 

candidates. They droned on with their all- 
too-familiar sound bites, while I tried to 
answer questions and propose real solu- 
tions, in the tradition of good medical 
problem-solving. When I emerged from 
the studio at the end of the debate, I was 
surrounded by people telling me I had won 
the debate, as indicated by the instant 
viewer poll being conducted online." 

In that moment Stein's understanding 
ot politics was turned on its head. "I sud- 
denly realized the obstacle to political 
progress is not the problem of persuading 
the public to support higher principles of 
justice, sustainability, and democracy," 
she says. "The public already shares those 
principles. The obstacle is not finding a 
better sound bite, or a more compelling 
message. The public already gets it. The 
hurdle is getting the word out to the pub- 
lic that there arc real solutions to the prob- 
lems they're already worried about — from 
the crises in health care and housing to 
global warming, economic and racial dis- 
parities, and our fraying social fabric." 

Getting the word out is no simple task, 
Stein acknowledges, but it is one she 
believes to be solvable, especially at the 
local level. "That's the beauty of a race for 
state representative," she says. "Such a race 
is for a small enough district that a candi 
date can actually talk directly to the voters 
without being at the mercy of big corpo- 
rate media or powerful campaign donors." 

In Stein's view, community values and 
a commitment to a better future are alive 
and well among the general public. "I 
have no doubt that people will make the 
right decisions if they have the benefit of 
a real debate — not just for an hour in an 
election season, but as a way of life. That's 
what democracy and a responsible press 
are all about. If we put that process in 
place, we can begin to move in the right 
direction — toward a healthy, just, peace- 
ful world. That's what people long lor, 
and it is within our reach." ■ 

Beverly Ballaro is associate editor of the 
Harvard Medical Alumni Bulletin. 





William .S.Jorda n.Jr. 
1 942 received the Albert B. Sabin 
Gold Medal in May for his 
research in the field of vacci- 
nology. Jordan is past director 
of the Division of Microbiolo- 
gy and Infectious Diseases 
at the National Institute for 
Allergy and Infectious Dis- 
eases, where he now remains 
active on a voluntary basis. He 
has devoted his professional 
life to promoting research 
on infectious diseases and 
vaccine development. 

Bruce Harris 

'43 A "My dear wife, Jody, passed 
away on July 6 after a long 
struggle with emphysema. We 
had celebrated our 60th wed- 
ding anniversary with much 
joy in February of this year." 

John W . Braasch 

1 946 "Due to editorial misadven- 
ture, the class note published 
under my name in the Spring 
2004 issue of the Bulletin was 
neither clear nor complete. 
The name of the patient on 
whom three operations for bil- 
iary stricture were performed 
was Anthony Eden (Lord 
Avon), the youngest foreign 
secretary in Great Britain's his- 
tory. In the period preceding 
World War II, Eden enjoyed a 
steady political ascent until, 
in 1939, he abruptly resigned 
his post as foreign secretary in 
protest of Chamberlain's policy 
of appeasing Hitler. Eden's 
potentially brilliant career 
was inadvertently sabotaged 
by complications from surgi- 
cal error during a cholecystec- 
tomy he underwent in 1953 
in London. When Winston 
Churchill suffered a stroke 
that year, Eden would have 
been his immediate likely 
successor, but he was still 

recovering from the first of 
three repair operations. Eden 
was appointed prime minister 
two years later and had to 
confront Nasser's nationaliza- 
tion of the Suez Canal, a major 
crisis for Britain. Eden's failed 
response to these events may 
have been partly affected by 
his continuing poor health. 
Eden was initially referred 
to Richard B. Cattell '25 of 
the Lahey Clinic. Cattell per- 
formed the first and second 
of the repairs. I operated on 
Eden the third time and 
found a shrunken right lobe 
of the liver, which contained 
an abscess. This was drained 
and stented. My account 
of Lord Avon's biliary tract 
saga appeared in the Novem- 
ber 2003 issue of the Annals 
of Surgery." 

Hermes C. Grillo 

1947 "In April I attended a sympo- 
sium in honor of classmate 
Morton Swartz, HMS profes- 
sor of medicine since 1973 and 
chief of the Infectious Disease 

Unit at Massachusetts General 
Hospital from its inception in 
1956 until 1990, and since chief 
of the Jackson Firm there. Mort 
was honored with a day-long 
event, which was liberally 
adorned with talks by his 
former students as well as by 
HMS Dean Joseph Martin. 
Classmate Holly Smith was 
the principal speaker at the 
dinner that followed at the 
Harvard Club. Others present 
included Pat Blum, Robert 
Hopkins, John Littlefield, 
Marvin Sleisenger, and John 
Stoeckle. In grateful appreci- 
ation of Mort's outstanding 
contributions to clinical med- 
icine, research, and teaching, 
funds are being raised to 
endow a professorship in his 
name at the HMS Academy." 

Henry G rune haum 

1952 Tm still working and still 
enjoying it." 

John Shillito,Jr. 

"Bunny and I are doing fine in 
North Carolina. This fall we 



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